From the monthly archives:

April 2008

Pandemic Flu for Survivalists

by Brian Carty, MD, MSPH
04-25-2008

Thanks to a strict naval quarantine, the island of American Samoa was virtually untouched by the devastating 1918 influenza pandemic which killed at least 50 million people worldwide. Would this strategy enable you to survive a flu pandemic? Probably not. You would have to live on an island and be able to enforce a quarantine, or you would have to completely avoid contact with the rest of society for the duration of the influenza pandemic, as long as a year or so.

Imagine that you, your family and friends have sequestered yourselves to escape a plague. Then suddenly you discover contagion in your midst. A chilling fictional account of a group of people in a similar predicament is found in Edgar Allen Poe’s short story “The Masque of the Red Death.” In this tale, a prince and his friends seclude themselves in a castle during an epidemic of an illness known as the “Red Death.” An elaborate masked ball is held. But a stranger is discovered who is not only costumed as a corpse, but as a victim of the Red Death. The stranger is unmasked; the Red Death has arrived:

The Masque of the Red Death -image from Allen Poe's short story

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    “And now was acknowledged the presence of the Red Death. He had come like a thief in the night. And one by one dropped the revellers in the blood- bedewed halls of their revel, and each died in the despairing posture of his fall. . . . And Darkness and Decay and the Red Death held illimitable dominion over all.”
    “The Masque of the Red Death”

Make Preparations Now

Now that’s a gruesome ending, but the history of plagues and epidemics teaches that isolation and quarantine alone often fail. Still, there are a number of steps you can take to prepare for the influenza pandemic which is certain to occur. When it will occur and what strain of influenza virus will be responsible are unknown, but influenza pandemics often cause an enormous number of serious illnesses and deaths.

Preparations include insuring basic food, water and shelter. Information from health departments, the Centers for Disease Control, and other entities will be vital. Face masks and frequent hand washing may be beneficial. Avoiding crowds in theatres, workplaces, schools, and the like may help prevent or delay infection, but these measures, as noted, are likely to be only partially effective.

Vaccination

In addition to these general infection-control measures, vaccines for H5N1 (avian influenza) are in development. Still, there is no guarantee that such vaccines will provide protection or will be available in adequate quantities. You should get whatever yearly flu vaccine is available. This will give you significant protection against the yearly epidemic flu virus or viruses and possibly some partial protection against pandemic flu.

Anti-Influenza Drugs

To hopefully prevent infection, anti-influenza drugs can be taken daily during a pandemic, as long as a year if necessary. If infection occurs, the drugs would be used for treatment. Various governments are acquiring flu drugs, but the quantities are sufficient to treat only part of the population for a short period of time. So once a pandemic starts, these drugs will be in short supply. Stockpile them now before you need them.

There are several antiviral drugs active against influenza. Both H5N1 (bird flu) and the flu strains which cause yearly epidemics are now resistant to amantadine and rimantadine. However, because the pandemic flu strain which eventually emerges may be sensitive to these drugs, you should stockpile amantadine or rimantadine. Both are relatively inexpensive. People over age 65 or who have impaired kidney function should not take amantadine.

There are two other drugs active against influenza – Tamiflu (oseltamivir), an oral drug, and Relenza (zanamivir), an inhaled drug. I suggest obtaining a one year supply of Tamiflu for each person to be protected. The cost for Tamiflu, 75mg twice per day for a year, is about $2700, not cheap, but there is no substitute for this drug. If you can’t afford a one year supply, spring for a three or six month supply.

You Will Need Prescriptions

Your physician will likely cooperate by giving you prescriptions for these medications. If not, find one who will. Law enforcement officials have intercepted counterfeit Tamiflu, so buy from a reputable pharmacy.

It’s also probably a good idea to stockpile some antibiotics to treat bacterial pneumonia which often follows influenza. My recommendations are azithromycin, levaquin, and linezolid.

People May Be Desperate for Anti-flu Drugs

If you decide to stockpile these drugs, don’t tell anyone. Furthermore, the need to protect your stash against robbery and theft is obvious.

Make Reasonable Preparations, Then Relax

Many aspects of pandemic flu planning are beyond the capacity of individuals. Even so, if you follow the above recommendations, you will have done everything reasonably possible to prepare for pandemic flu.

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click to enlarge image

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Art by Nacho Garcia

Mr. A, a 35-year- old single Caucasian man, consulted a psychiatrist with a complaint that “I am supposed to be a 35-year-old, but I want to be a baby. I won’t ever get married or have kids if I am stuck as a baby.” His desire to be a baby interfered with his interpersonal relationships.

Dressed like a baby

The patient arrived for his appointment dressed as a child in Winnie the Pooh overall shorts and a Winnie the Pooh shirt. He spoke in a soft, childlike voice and had a strong odor of baby powder. He had a pacifier in his pants pocket and a diaper bag which contained a baby bottle, bib, baby blanket, and adult diapers.

Mr. A’s history

Mr. A had wanted to be a baby since age 12. He began wearing diapers secretly at age 17, but occasionally wore his baby clothes in public. He stated that he wanted “to be taken care of by a mommy who can hold me and rock me and give me a bottle.”

Sexual stimulation from wearing diapers

Mr. A was socially isolated and spent most of his free time at home engaging in baby activities. He wore diapers and baby clothes, slept in a crib, drank from a bottle, ate baby food, and played with blocks, cars, and Play-Doh. Mr. A was sexually stimulated by wearing his diapers and masturbated while wearing them several times a day. He also urinated and defecated while wearing his diapers.

Functions normally at work

Mr. A worked in law enforcement and lived alone in an apartment. He did not feel like a baby at work. He was adopted and had no history of medical problems, childhood abuse, depression, anxiety, or psychosis. He described his sexual orientation as heterosexual but had never had a sexual relationship.

Bizarre behavior in the psychiatrist’s office

During the psychiatric interview, Mr. A seemed anxious and embarrassed. During the interview he lay down, sucked his bottle and stared seductively at the female psychiatrist. He made little progress in psychotherapy and eventually terminated therapy after stating that he liked being a baby and was not sure he wanted to change.

“Adult babies” may be more common than we think

The adult baby syndrome is thought to be rare and is not yet included in psychiatric textbooks. However, the syndrome may be more common than we realize. Psychiatrists may not see many adult babies, but the most likely explanation is that adult babies generally don’t believe that anything is wrong with them and are unlikely to seek treatment. Hundreds of internet websites give adult babies opportunities to meet and play together, chat online, view photos and videos, and buy supplies such as plastic pants, adult baby clothes, cribs, baby furniture, bottles, and diapers. Many of these websites are overtly sexual and advertise adult baby-sitting services, dominatrix services, and the like.

What type of psychiatric disorder is the adult baby syndrome?

The wish to be treated as a baby is reminiscent of the sadomasochistic wish to be abused by a dominating individual. The adult baby syndrome might best be considered a paraphilia. A paraphilia is a form of sexual deviance involving sexual arousal by unusual and bizarre imagery or acts. The acts and imagery might include inanimate objects, pain and humiliation, children, or other unwilling or unsuitable partners. Voyeurism and pedophilia are examples of paraphilias.

Professional help is not always helpful

You may wonder what happened to Mr. A. Don’t you suspect that his life has probably not changed much? Professional help is not always helpful, and the physician should obey Hippocrates’ injunction “to cure sometimes, to relieve often, to comfort always.”

Case presentation from November 2003 American Journal of Psychiatry

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Medical Image of the Month April 2008

by Brian Carty, MD, MSPH
04-01-2008

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A US postal stamp commemorating George Papanicolaou (1883-1962), a physician who invented the Pap smear, a test used to screen for cancer of the cervix.

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Aunt Tilly’s summer picnic was happy, relaxing, and sunbaked. The chicken salad and cole slaw were sunbaked too, and you wondered how long these items had been unrefrigerated. Questioning your aunt’s food sanitation practices was certain to cause a family squabble, so you ate lunch and hoped for the best.

Acute Infectious Diarrhea and Antibiotic Use - Cartoon
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art by Nacho Garcia

Aunt Tilly’s Revenge

Your tact and optimism were not rewarded. A day later you began to have abdominal cramps and diarrhea. You vow zero tolerance on food sanitation in the future.

You have “Montezuma’s revenge,” “the runs,” “the squirts” – acute, sudden onset infectious diarrhea, also known as acute gastroenteritis. You call your physician’s office and are told to take fluids. You are told that the diarrhea will “run its course.” Although on average antibiotics decrease the severity and duration of this illness, you don’t get a. prescription for antibiotics. Why not?

Antibiotics Clearly of Benefit for Acute Diarrhea

The answer is not simple or straightforward. Although well-controlled studies show that antibiotics are beneficial for traveler’s diarrhea and for domestically acquired diarrhea, experts generally recommend not giving antibiotics to patients with these problems.

Textbooks’ Recommendation: No Antibiotics

For example, the Lange 2008 Current Medical Diagnosis and Treatment advises that “antibiotic treatment of all patients with acute diarrhea is not indicated.” The 2005 Mandell’s Infectious Diseases states that “Specific antimicrobial therapy for infectious diarrhea is indicated in a limited number of situations.”

Clinical Trials Show a Benefit for Antibiotics

Textbooks and journals have lengthy, complicated recommendations for acute diarrhea evaluation and treatment which have never been tested in clinical trials. However, what has been tested in multiple clinical trials is the comparison of antibiotics to inactive placebo. Patients given antibiotics consistently have a duration and severity of illness about half that of the patients given placebo. The suggestion that acute gastroenteritis should be allowed to “run its course” with fluids and no antibiotics (although fluids are important) is at odds with the available medical research results.

Objections to Antibiotics

You may want some good reasons why a doctor isn’t going to decrease your suffering when he is capable of doing so, even if it’s only by a couple of days. One reason given not to prescribe antibiotics for acute gastroenteritis is that diarrhea can be the initial symptom of other more serious illnesses which require different management. However, this is a meaningless argument, because you have to make a correct diagnosis to treat any disease appropriately.

Another objection to antibiotic use is the possibility that some patients with acute diarrhea may be infected with antibiotic-resistant organisms. However, the patient usually does well if the doctor makes an intelligent initial antibiotic choice, orders lab tests if necessary, and closely monitors the patient.

Drug Side Effects

Drug side effects can be avoided by not prescribing antibiotics, but side effects are usually minor for the antibiotics used to treat acute infectious diarrhea. Of course, any antibiotic can cause potentially severe antibiotic-associated colitis, but the antibiotics used to treat infectious diarrhea rarely cause this problem.

Small Chance of Making Things Worse

The potential for actually causing antibiotic resistance is another reason given to avoid antibiotic use. This is usually a concern for the population as a whole and not for the individual patient, and the physician’s main concern is the individual patient. Another concern is that antibiotics can actually make a gastroenteritis patient worse, but the risk of this occurring is small and, at present, only theoretical.

What’s Wrong With a Little Suffering?

Finally, here is the least supportable reason given for withholding antibiotics. Many physicians feel that since acute diarrhea usually runs its course in a few days with no permanent ill effects, antibiotics, even though beneficial, are unnecessary and should be withheld. This practice is completely at odds with the physician’s duty to minimize suffering if this can be accomplished without doing more harm than good. Do you think most doctors with acute infectious diarrhea would suffer without treatment, or would they grab a few tablets of ciprofloxacin or azithromycin off the shelf? The latter, most likely.

A Balanced Approach

Certainly, every acute diarrhea patient should be evaluated carefully. Treatment should be tailored to the individual patient. However, expert management recommendations usually assume that the patient should not be treated with antibiotics unless there is a very strong reason to give them. It makes more sense to treat most patients with acute diarrhea with antibiotics unless there is a very good reason not to do so.

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