Charlie goes to Medical School

Just a quick post.  Patient HM is a famous patient with amnesia.  I haven’t actually had time to look into his story with my own studying going on, but I’ve been watching the microtome video while studying (and when I’m supposed to be studying).

They did a lot of the frontal lobe last night and are right now in the genu/rostrum/body area of the corpus callosum.  If you haven’t had neuroanatomy yet, this is where the brain anatomy gets interesting.  The middle third in any axis is where most of your smaller structures are located, and also where most of our neuroanatomy lab focused for the last exam.

Exciting stuff.

Here’s the link to the video:
http://thebrainobservatory.ucsd.edu/hm_live.php

And some other links:
http://science.slashdot.org/story/09/12/02/2248233/Brain-of-Patient-HM-Brain-Being-Sliced-Streamed-Live
http://en.wikipedia.org/wiki/HM_%28patient%29

Vacuna Influenza by alvi2047

Prevention and Control of Seasonal Influenza with Vaccines, Recommendations of the Advisory Committee on Immunization Practices (ACIP), 2009 – MMWR – Early Release

While I am packing, here is something to tide yourself over while I am not writing.  I wrote a couple of posts about the novel influenza A H1N1 virus (a.k.a. swine flu) a while ago.  One question that arose following the initial reports was about vaccination for this year.  I haven’t been eagerly awaiting this report, but now that it is out I am eager to read it.

I don’t have time to read it over, but wanted to push it out to everyone especially since the CDC decided to push the report early.

http://www.flickr.com/photos/alvi2047/ / CC BY 2.0

We here at Charlie Med School send our best to Lee Corso who had a minor stroke.  They are expecting no permanent damage and he is planning to make it back for the start of the season.  Here’s to a speedy recovery.

If you suspect someone is having a stroke, here’s a mnemonic device to help you remember first aid.  FAST.

Face - Ask the individual to smile.  Look for drooping.

Arms - Ask the individual to raise both arms.  Look for drifting downward.

Speech - Ask the individual to repeat a sentance.  Can they repeat it?  Is there slurring?  Is there confusion?

Time - Act quickly.  Call 911 if the person is showing any symptoms.  Immediate medical assistance is imperative. Think Fast.

F-A-S-T.  Fast.  There are a number of other symptoms (list on wikipedia).  On thing to look out for is that strokes usually act on one side of the brain and therefore act on one side of the body, but if you are concerned you should seek immediate medical attention regardless.

A stroke is the loss of brain function due to a disruption of blood flow in the brain.  Because of the nature of nerve cells, a constant supply of oxygen and glucose is necessary to maintain homeostasis (there is no ready reserve such as in muscle cells).  Strokes can occur because of blockage from an infarction (ischemic stroke) or from the loss of blood from circulation in the brain (hemorrhagic stroke).  The disruption of blood supply to part of the brain will lead to tissue death in a matter of minutes, so time is of the essence when dealing with a stroke.

And a speedy recovery for Lee Corso.  I’m sure that I will be disagreeing with the things that he says on Saturday mornings soon enough.

New York City Official Is Obama Pick for C.D.C. (N.Y. Times)

Dr. Frieden, a 48-year-old infectious disease specialist, has cut a high and sometimes contentious profile in his seven years as New York’s top health official under Mayor Michael R. Bloomberg. He led the crusade to ban smoking in restaurants and bars, pushed to make H.I.V. testing a routine part of medical exams, and defended a program that passes out more than 35 million condoms a year.

It is my goal to keep this blog from getting into political issues.  However, it is important to follow these events as they purtain to matters of public health.  The CDC has many challenges to face over the next few years, and hopefully Dr. Frieden will be able to keep the focus where it should be as the agency moves forward.  In the past, he has shown the ability to keep public health matters a priority, even if sometimes being “contentious”.

One example that stands out is the push against tobacco and the smoking ban.  The push to ban smoking in bars and restaurants was met with a good deal of opposition.  However, since the New York City ban several other states and municipalities have made similar moves…including the top tobacco-producing state in the country.

One of the hard things about being a doctor (or so I’m guessing) is getting people do to things that will be good for them…the things that they don’t want to do.

The CDC has long been thought of in the context of some of the more exotic disease outbreaks, but the agency also has the responsibility for a broad spectrum of health matters including everyday issues that can help improve the public health.  Given his past work, it will be interesting to see how Dr. Frieden fares in his new role.

This is a story that I heard about before, but I’m posting about it today because it was mentioned on Security Now this week.

Conficker worm found in hospital equipment Mercury News

Apparently, hospitals are taking devices which shouldn’t be connected to the internet and they are then hooking them into the internet.  These devices have relatively unpatched versions of Microsoft Windows.  Since these devices aren’t meant to be hooked up to the internet, the manufacturers do not keep up with updates to the OS.

Here’s the first problem, the FDA requires a 90 day notice for updates to the firmware of medical devices.  The computer virus basically has two life cycles.  Either the virus is in the wild before the patch (i.e. zero day).  Or the patch goes out (the patch for the security hole that Conficker uses went out in October last year) and then gets reverse engineered as soon as it is released by the people who write viruses.  So, if the patch had been submitted to the FDA, it would have been updated in January.

The second problem, is that no one was paying attention since these devices aren’t supposed to be connected…so here we are in May, and security experts are now noticing that devices like imaging machines are sending out for instructions.

I’ve been sitting here theorizing about how this works, but I’m not really sure how.  I mean, if the machine is reaching out to the internet on its own (not through a terminal) then it must have an ethernet port.  But why would a medical device have an ethernet port if it isn’t meant to be connected to the internet.  This may be how the machine gets up.  In the day, devices would have a special serial port in the back that would allow for the machine to be set up.  This may now have been replaced with an ethernet port since no one has serial ports on their machines any more.

In any case, this is a problem, but probably not a huge one.  First off, this is probably a scenario that a virus writer would not have thought about…yet.  Viruses that are meant to gather data are usually aimed towards financial data (so this would be more of a problem for a cash register).  Second, there isn’t a whole lot of money in your personal medical data.  You might get a situation where a virus author can blackmail the hospital for hush money, but there are just easier and more lucrative targets for virus authors.

The problems come where a machine starts trying to do a DDoS attack or starts sending out spam.  Medical devices may not have the greatest computing power, and a virus can eat up a lot of a machine’s resources.  This could theoretically slow down a machine until it malfunctions.  Additionally, there is a new concern where an unrelated trojan, Zeus, issued a command to a botnet which self-destructed 100,000 PCs (or rather their OS).  There really isn’t a great reason to do this for someone running a botnet, but now it has been done.  The machines obviously didn’t physically blow up, but would you like to have an MRI machine bluescreening on startup?

Chances are, a lot of these devices should have an ability to reimage with the original firmware.  Reimage machines, unplug embedded devices from the network (or create an internal network which is separate from internet), and stop using removable storage (USB keys)…then you should be good until patches start coming.  However, now that this has happened, security of medical devices should now be an important part of any medical facility…even if that security is ensuring that your devices stand alone.

I’ve got two finals today, so here’s some material to read while I’m busy.

WHO – Pandemic Phases

CDC – Pandemic Phases

This is a description of the phases of a pandemic.  Although this is just a model, there are some things that I’ve noticed at first glance.  First off, these are based on an animal-human species jump.  While animals are a common source of emerging diseases, occasionally there are other sources (e.g. salmonella and fresh produce).  Secondly, the verbiage appears to not account for globalization enough.  The fact of the matter is that with most diseases there is an incubatory period during which there are no symptoms, and for more and more diseases you can now get from anywhere in the world to anywhere in the world before any symptoms show up.

The swine flu has demonstrated a more modern model of dissemination where the disease was identified, the people worldwide start looking for it, and then we start seeing the map fill out.  The effort at that point becomes tracking the localized spread on a worldwide basis, i.e. local public health efforts coordinated through national and international organizations.  However, this is all based on my junior level microbio class.

Anyway, the watchword has been concern, not alarm.  And it still should be.  The map is filling out quickly, but only because we know what to look for.  Enjoy some reading while I venture out into public and breathe a lot while taking my tests.

So, I have just learned my first lesson…put the name of the new flu strain in the post title.

News outlets are already referring to this as a pandemic and rightfully so.  There are reported cases in Canada and New Zealand as well as Ohio now.  I’ve also heard Hong Kong and Spain.  Although these are somewhat isolated cases, this does paint the picture of an emerging infectious disease in the modern age of globalization.

However, this is all off the internet.  I suspect there will be some major announcements made tomorrow when more people are listening.

Here’s a google map aggregation of the reports.  Here’s another one…the RSOE Emergency and Disaster Information Service alert map…but that one has everything.

Edit: Here’s another RSOE site.

New Flu Strain Appears In the US and Mexico (via Slashdot)

Bullet points:

• The Flu is a segmented RNA virus.  This means that it’s genome is broken up into 7 or 8 pieces.
• Bird Flu is particularly virulent, but does not typically spread through respiratory methods because its reservoir is in the GI tract.
• When people are concerned that the Bird Flu could become airborne through mutation, this is not really the case.  The concern is that one organism could undergo concurrent infections and these pieces could shuffle.  The concern is that the virulent strain gets the ability to pass through respiratory methods.
• It is believed that this was the case with the 1918 flu epidemic.
• Swine flu is believed to contain portions of bird, swine and human influenza strains.
• They are referring to this as H1N1 Swine Flu where H1 and N1 refer to the specific type of hemagglutinin and neuraminidase surface proteins on the virus envelope.

…

• It is unlikely that a scenario like 1918 would ever occur again with a virulent flu virus.  Just to show how much our understanding of diseases has grown, at the beginning of the 20th century the germ theory of disease was not taught at every medical school.  Tobacco Mosaic Virus was the first virus to be discovered only 20 years before.  Back then, most people didn’t know what a bacteria or a virus was.
• That being said, this is being considered a public health emergency by the WHO and measures are being taken.  Mexico City is starting to shut down schools and public events and such.  I would expect travel advisories and such.
• For the time being, the concern here has been localized to the US-Mexican border.  However, Kansas has confirmed two cases and New York has eight suspected cases.
• Given the media coverage that the flu gets every year, the general public probably knows what the “flu-like” symptoms are.  If you are running a fever with cough or a runny nose in the areas of concern (TX, CA, etc.) you should contact your health care provider.  Other symptoms are aches, nausea, vomiting and diarrhea.
• The demographics for this outbreak are very different than normal flu outbreaks.  Typically the flu affects the very young or very old.  The majority of people being affected by this outbreak are otherwise healthy adults.
• Based on the numbers in these reports, mortality looks low compared to H5N1 which typically results in death around 60% of the time (from Wikipedia).  But again, these are the numbers in the reports that I’m just looking at (~60 suspected deaths, ~1000 suspected cases…these obviously are not official numbers).  However, if the majority of those affected are otherwise healthy adults, I would expect this ratio to rise once as the disease spreads and other demographics start becoming infected.
• There is human to human spread of this disease, but the main thing that is not known is how easily this is spread.
• There isn’t a vaccine and there won’t be one for a while.  Flu vaccines are slow to produce.
• Preparations for H5N1 have helped prepare for identifying and containing this outbreak.
• Here are some pages with information about the outbreak and prevention: CDC – Swine Flu, WHO – Swine Flu, CDC – Prevention, PandemicFlu.gov
  

Given that this has already crossed the border and that epidemic and outbreak basically mean the same thing (a higher number cases than usual), you could technically call this a pandemic.  However, they typically don’t use terms like epidemic and pandemic during the outbreak to keep down unnecessary panic.  The most annoying question that you will hear in media coverage is going to be “Can we call this a pandemic now?/When can we call this a pandemic?”  Mass media makes a lot of their money on panic.  However, there is reason for concern, and people are working on it.

Anyway, don’t run for the hills.  Stay informed, know what to look for in symptoms and practice good hygiene to protect your self.

Keep in mind that most of the deadliest diseases on this planet are the ones that you never hear about.  You’ll probably hear about this ad nauseum, but there are diseases like Tuberculosis and Malaria which never get reported about.  There is cause for concern which is why there are good people working on this and why you should stay informed.  Just don’t go buying into all the hype that is going to get put out there.