Amputation and Prostheses in Haiti

As government agencies and non-governmental organizations flood Haiti to provide relief support, many are finding a lack of even the most basic medical equipment and supplies. Even before January 12^th, Haiti’s healthcare system was unable to fully support the needs of the Haitian population which included 800,000 individuals with disabilities, and life-saving medications were in short supply but high demand. While outbreaks of tuberculosis, HIV, and cholera are the current major public health concerns, insuring the provision of rehabilitation services to the estimated 200,000 (some reports indicate 250,000) individuals who have undergone amputations as a result of the earthquake are especially pressing. This figure includes not only the 2-3,000 individuals who have had amputations of major bones as well as the thousands more who have fingers or toes amputated (per personal correspondence with Al Ingersoll, CP; Healing Hands for Haiti).

Without proper medical equipment and often in unsterile conditions, physicians providing care in Haiti since the earthquake struck have had to amputate the limbs of individuals who otherwise would die. The social stigma attached to individuals with disabilities in Haiti and other developing nations has led some Haitians to leave gangrene infections untreated, as they would rather die that face the prospect of living without an arm or leg. In addition to possible infection at wound sites, individuals who have suffered “crush injuries” or rhabdomyolysis are at risk developing kidney failure when the crushed muscle ruptures. Studies indicate that between four and 33 percent of patients with rhabdomyolysis develop kidney failure, but amputation of the affected limb has the potential to save the patient’s life. In order to perform these amputations, CNN reports that some surgeons have had to use “civil war medicine” – amputating limbs with saws and other instruments, often without anesthesia. Some estimates indicate that as many as 95 percent of Haitians who suffered crushing injuries in the earthquake will undergo amputation.

Haiti’s hospitals sustained considerable damage and what remains of the Haitian healthcare system has been overwhelmed by the demand of those in need of medical services. To fill this gap, clinics run both by local hospital staff and international aid organizations have been setup in tents outside the devastated buildings. Reports indicate that surgeons at University Hospital, Port-au-Prince’s largest hospital, performed approximately 225 amputations within the first few days following the earthquake. Though statistics are not available yet for the number of new amputees, Mirta Roses, director of the Pan American Health Organization, has indicated that some hospitals have reported performing as many as 30 amputation surgeries per day. Limitations of space, medical personnel, and other resources have forced many makeshift Haitian surgical wards to discharge individuals after amputations are completed, overloading what remains intact of Haiti’s fragile hospital system with patients in need of post-operative care. To assist further assist these individuals, organizations like Healing Hands for Haiti, Handicapped International, and Doctors Without Borders are making efforts to provide surgical and post-operative care following amputation. Additionally, Global Relief Technologies has introduced a system that allows for critical information about patients to be collected and uploaded to a PDA so that this information can be shared with other aid organizations to ensure high-quality care for all amputees.

In addition to the importance of post-operative care, individuals who have undergone amputation are in need of prostheses, but the devices commonly used in the developed world may not be best suited for use in Haiti. An average prosthesis can cost between $4,000 to $6,000 and in the United States a new amputee could expect to undergo a minimum of four fittings a year for the life of the prosthesis to ensure that the device is comfortable – in Haiti this is simply outside the realm of possibilities. Low-cost, high-quality devices developed by non-profit organizations, including the Center for International Rehabilitation (CIR) and Legs for All may be applicable for use in Haiti. Developed specifically for use in areas with limited resources, the Center for International Rehabilitation’s CIR Casting System could allow for the rapid fitting of Haitian amputees. Unlike traditional plaster-based prosthetic fabrication methods, the CIR Casting System uses a fabric bag filled with polystyrene beads and allows for the fabrication of prostheses in a fast, simple, and low-cost manner. A final prosthesis can be fabricated in less than two hours during a single clinical visit, compared with at least two clinical visits using traditional plaster-based methods. In addition to the development of this innovative fabrication method, the CIR conducts blended distance learning initiatives that combine online training with hands-on workshops to familiarize local technicians with the fabrication method. Since 2008, following trainings in Thailand and India, over 2,500 individuals have been fitted using the system and it has been widely accepted in these regions. However, as Jeffrey Bigelow, resident neurologist at Yale University who completed a survey of the needs of Haitian amputees for Healing Hands for Haiti in 2004, notes,  it is important to recognize that even when using this type of appropriate technology, “devices need to be skillfully made or they’re just too painful to wear.”

Dr. Steven R. Flanagan, medical director of the Rusk Institute of Rehabilitation Medicine at NYU Langone Medical Center, noted that even in the best of circumstances, when an amputation site can be properly cared for, it can take four to six months for a traumatic amputation to heal completely. Even before they can be fitted, many of Haiti’s new amputees will require counseling to come to terms with their new lives as a part of Haiti’s generation of amputees.

Specialty physicians who wish to offer teleconsultation support to disaster-relief workers in Haiti, Health professionals who wish to provide volunteer support on the ground in Haiti, and U.S. healthcare institutions that are willing to provide services to victims of the earthquake who are airlifted to this country for urgent medical or rehabilitation care can register through iCons in Medicine.

Find out more about The Center for International Rehabilitation and the CIR’s innovative prosthetic technologies

Helping Haiti

As the devastation of the 7.0-magnitude earthquake that hit Haiti on January 12th continues to unfold, public and mental health experts are likely to be at the fore of those monitoring the situation. In addition to the immediate needs of survivor rescue, survivors of earthquakes and other natural disasters are at risk of malnutrition, parasite infection, and post-traumatic stress disorder and depression. While it is important to ensure that emergency medical care is delivered to those in need, it is also critical that a plan be put in place to ensure that infection and stress disorders are recognized and treated efficiently.

Time magazine reports that before the earthquake, Haiti was one of the poorest countries in the world. No Haitian city had a public sewage system, less than half of the population had access to drinking-water services, and malnutrition and disease affected a large portion of the population. According to CNN, the Red Cross has estimated three million people – one-third of the total population of Haiti – are affected by the earthquake. Many of those not among the reported 200,000 who lost their lives were seriously injured and will likely require amputations or other surgeries. As time passes, these acute health problems will be replaced by chronic heath conditions that may worsen quickly if individuals are not receiving treatment.

According to Columbia University public health expert, Josh Ruxin “The number one risk [following a natural disaster] is always bacterial infections where they have open wounds.” Without antibiotics and proper treatment, wounds can become infected and put individual’s health at risk. Though some were not physically harmed by the earthquake, reports indicate that 40,000 were left homeless and forced to “cluster together in public places without food, clean water or sanitation.” For individuals displaced by earthquakes or other catastrophic situations, the risk of contracting diseases or developing parasitic infections is increased. Water supplies can become contaminated quickly in refugee camps or settings with damaged potable water distribution systems, leading to a rapid spread of water-borne illnesses such as cholera and dysentery as well as diarrhea, malaria, and measles.

Some experts note that not all of the harm of this disaster will be physical. Dr. Daniella David, professor of clinical psychiatry at the University of Miami’s Miller School of Medicine, explains that “Once the initial resources are in…is when the psychological aftereffects are going to hit people.” Further, she explains, there is a normal and immediate stress response that accompanies a devastating effect that causes damage to homes and loss of friends and family members. According to Sandro Galea, chair of the Department of Epidemiology and Columbia University’s Mailman School of Public Health in New York City, acute stress, post-traumatic stress, and depression will likely be seen in Haiti at three to four times higher than baseline in the coming months. Symptoms of post-traumatic stress disorder (PTSD), including depression, anxiety, emotional numbing, and sleep disorders, are usually seen within three months of the incident, according to the Canadian Mental Health Association. According to experts, assistance for potential sufferers of PTSD – often called “psychological first aid” – includes making individuals aware of what signs and symptoms to watch for, and letting them know that their feelings are normal and that help is available. While reporting of PTSD and other psychological disturbances is frequently a concern due to the social stigma attached to mental illness, Haitian-born psychologist Marie Guerda Nicolas of the University of Miami indicates that Haitians tend to be expressive of their grief and psychological distress. Further, members of rescue teams from other nations at as great a risk, if not an increased risk, of developing PTSD or psychological trauma.

Though a global humanitarian response is currently underway, aid organizations face a daunting task as they attempt to coordinate vast amounts of aid relief and get it to individuals who require it urgently. It remains to be seen exactly how many were affected by the earthquake and if assistance can be delivered effectively to them, but the impact of the earthquake on Haiti and its people is likely to continue after the initial wounds have healed.

Specialty physicians who wish to offer teleconsultation support to disaster-relief workers in Haiti, health professionals who wish to provide volunteer support on the ground in Haiti, and U.S. healthcare institutions that are willing to provide services to victims of the earthquake who are airlifted to this country for urgent medical or rehabilitation care can register through iCons in Medicine

On Neglected Tropical Diseases

Malaria, HIV/AIDS, and tuberculosis are often considered the most pressing disease-related threats to individuals in the developing world and the quest to eradicate them receives a large portion of government and private funding. However, a group of conditions known collectively as neglected tropical diseases (NTDs) have a more widespread and devastating effect on the lives of people in many regions of sub-Saharan Africa, Southeast Asia, and Latin America. These regions account for up to 90 percent of the disease burden for this group of 13 parasitic and bacterial conditions. Reports from the Global Network for Neglected Tropical Diseases indicate that these parasitic and bacterial infections affect over 1.4 billion people, most of whom survive on less than US$1.25 per day. While NTDs may not necessarily kill those infected, they can lead to malnutrition, anemia, a range of disabilities (most often blindness), stunted growth, and greater susceptibility to other illnesses.

Clockwise from top left: An egg of the roundworm, which causes Ascariasis; a man with Lymphatic Filariasis being examined by a physician; the whipworm, which causes Trichuriasis; and a child receiving antibiotic treatment for Trachoma.

Individuals affected by NTDs live primarily in tropical and subtropical climates, and many experience more than one infection or parasite at a given time. According to the World Health Organization (WHO), the majority of individuals affected by NTDs live in remote and rural areas, urban slums, or areas experiencing conflict situations. Seventy percent of infections occur in low- or lower-middle income areas, and are frequently caused by unsafe water and poor housing and sanitation conditions. Further, NTDs contribute to a cycle of poverty in which children are likely to become infected due to their poor living conditions, and once infected they may experience delays in cognitive development inhibiting their ability to escape their impoverished conditions.

The seven most common NTDs are: Ascariasis, Hookworm, Lymphatic Filariasis, Onchocerciasis, Scistosomiasis, Trachoma, and Trichuriasis. These diseases, many of which are caused by parasitic intestinal worms known as helminthes, have the most devastating impact on those who contract them. For example, Ascariasis, resulting from roundworm infestation, affects 800 million people; and trichuriasis, resulting from whipworm, affects 600 million. Helminths rob children of nutrients and can lead to stunted growth, iron-deficiency anemia, and protein malnutrition. They are at an increased risk of contracting parasitic worms, as are the elderly and pregnant women. Over 40 million pregnant women are infected with hookworms, parasitic worms that attach to the small intestine and suck blood from their host, increasing vulnerability to malaria and additional blood loss during labor.

Based on Disability-Adjusted Life Years (DALYs), which refer to the years of healthy life lost to disability or premature death, NTDs are a greater health burden than tuberculosis or malaria, and approach the level of burden of HIV/AIDS. In addition, NTDs are the cause of approximately 534,000 deaths worldwide each year. Through programs to distribute medications, the WHO, pharmaceutical companies, government agencies, and international aid organizations hope to ensure fewer lives are lost. Coordinated efforts have allowed for the rapid deployment of inexpensive diagnostic tools, medications, and treatments, many of which can be administered by trained non-medical staff including teachers and community health workers. Medications are often distributed in “rapid-impact packages,” reducing costs and putting less strain on already weakened healthcare systems in the areas where NTDs are most prevalent. These packages also offer the opportunity to bundle life-saving drug treatments with other interventions such as antimalarial bed nets or nutritional supplements.

Through these and other similar efforts, it has been possible to reduce the occurrence of a number of conditions in many parts of the world. The number of cases of guinea worm disease, also known as dracunculiasis, has fallen from 3.5 million in the 1980s to just 4,619 in 2008, and the WHO has declared eradication in Nigeria and Uganda. Many other conditions are now found only in remote villages and are nearing total eradication through education programs, medication distribution, and improved sanitation.

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Tobacco Use Worldwide

Currently, approximately one third of the global population over the age of 15 – about 1.1 billion people – smoke cigarettes. Tobacco use continues to be the leading preventable cause of death worldwide, killing at least five million people each year. Trends from illness and death related to tobacco use indicate that by 2030, tobacco use will contribute to the deaths of more than 10 million people worldwide each year, 70 percent of whom live in the developing world. Though various strategies are in place, including bans on smoking in public areas, restrictions on advertisements for tobacco products, and increased taxes on cigarettes, the number of people who use tobacco has not significantly decreased. A recently released report from the World Health Organization (WHO) details cigarette and smokeless tobacco consumption and seeks to find an approach that may lessen the use of these products.

The WHO report indicates that though 22 of the world’s most populous 100 cities are now “smoke-free,” this only accounts for 5.4 percent of the world’s population. In 2008, the WHO established a set of guidelines aimed at helping nations to reduce smoking, which include:

1. Monitoring tobacco use and the policies to prevent it,
2. Protecting people from tobacco smoke,
3. Offering people help to quit using tobacco,
4. Warning people about the dangers of tobacco,
5. Enforcing bans on tobacco advertising, promotion, and sponsorship, and
6. Raising taxes on tobacco.

However, reports indicate that less than 10 percent of the world’s population is covered by any one of these measures. Additionally, only two percent of individuals live in nations that have comprehensive and widely-accepted smoke-free laws, and 94 percent are not protected by any laws against smoking.

Laws banning smoking – including the use of cigarettes, cigars, and hookahs – in public places will come into force in 2010 in many areas of the world. According the Syrian Society for Countering Cancer, 60 percent of adult men and 23 percent of women in Syria smoke, and 98 percent of Syrians are affected by second-hand smoke exposure. Other nations face similarly high rates of tobacco use and smoking-related illness and death. The high incidence of tobacco-related deaths in the Philippines (90,000 per year), Malaysia (10,000 per year), and Vietnam (40,000 per year) has caused concern in these regions, but fully effective smoking bans are not yet in place. Reports indicate that the majority of smokers in some Southeast Asian countries are men, and that as many as 75 percent of men smoke, compared to fewer than 20 percent of women who do. In Cambodia, for example, roughly half of the older women do use tobacco, but favor smokeless chewing tobacco, which many women begin during pregnancy to help lessen prenatal nausea.

Over the past four years, smoking rates have decreased in developed nations including the United States, Japan, and Western Europe as anti-smoking laws gain momentum. However, the World Lung Foundation (WLF) indicates that “More than 80 percent of those with premature deaths [from smoking] would occur in low- and middle-income countries.” Since 1960, according to the WLF, “the global production of tobacco has increased 300 percent in low- and middle-resource countries while dropping more than 50 percent in high-resource countries.” In China and India, over half a billion men consume tobacco, and other nations are facing similar problems of mass consumption of tobacco use. Tobacco is a contributing cause to heart attacks, strokes, diabetes, cancers and asthma worldwide, regardless of how it is consumed (smoked, chewed, etc.). According to Ala Alwan, the WHO non-communicable diseases expert, more than 80 percent of the WHO’s projected cancer deaths are likely to occur in the poorest regions of Africa. To increase awareness and provide education about the dangers of smoking, the WHO is planning to establish a regional hub there in 2010.

It remains to be seen how much impact the efforts of the WHO and other organizations will have with regard to decreasing the number of individuals who use tobacco. Through newly established laws, increased taxation, and outreach and education about the dangers of cigarettes and smokeless tobacco products, it may be possible to urge individuals to quit smoking or not to start at all.

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Appropriate Technologies

The primary goal of the iCons in Medicine program is to create a community of healthcare professionals, enabled by appropriate technology to build bridges and forge connections across geographic, social, cultural, and ideological boundaries to make high-quality medical knowledge available wherever medicine is practiced. Appropriate technology is not necessarily items that are high-tech or low-tech, and may not be commercial off-the-shelf items. Rather, appropriate technologies are those that best combine suitability to the task at hand with compatibility with the technological, cultural, and economic framework of the region where they are deployed. Groups of researchers, universities, and not-for-profit and for-profit companies have all begun making strides to create healthcare tools that can be utilized in areas that may lack trained medical staff, resources, and/or reliable Internet connectivity, as well as other regions worldwide.

Health IT advancements and web-based tools offer an opportunity for physicians and healthcare workers to use technology in ways that previously were not available. Mobile applications for iPhones are gaining popularity among healthcare providers in the developed world. The BBC reports that, per Manhattan Research, 64 percent of U.S. doctors currently own a smartphone, and this figure is expected to rise to 81 percent by 2012. Most popular smartphone-based apps are available for the iPhone, among these tools are those that allow for collaboration between healthcare providers working in country, and remote consulting physicians. Among these are the iStetho Adapter and iStethoscope Pro app, developed by RidRx, which allow for audio information to be captured via a stethoscope modified for use with the adapter to be translated into sound spectrograms.

For some physicians in the United States and other areas of the developed world, high-tech solutions provide an opportunity to provide the best quality of care. Dr. Dinesh Patel, iCons in Medicine Member and Chief of Arthroscopic Surgery at Massachusetts General Hospital, finds that in his practice, new imaging and lens technologies have had the greatest impact. Technologies, which are “constantly evolving as high-tech experts bring new ideas,” bring cost reductions and improved health outcomes, as well as reducing complications and insurance costs, according to Dr. Patel. President of the American Telemedicine Center Corp., Dr. Gildred Colon Vega, also utilizes computer-based solutions in her practice at the San Juan Health Centre. Dr. Colon has found that an electronic medical record technology known as Web (based) Disease Management Electronic Medical Record (WebDMEMR) has been especially useful for storing clinical trial information.

Areas of the developing world are also making use of many of these high-tech solutions, including smartphones, and computer-based and mobile applications. The lack of trained staff have led physicians at one eye hospital in India to employ the use of mobile technology to improve its reach in rural and semi-urban areas. By training individuals in rural areas to take retinal images that are then sent to doctors’ iPhones at the hospital in Bangalore, providers are better able to ensure that infants are treated quickly if Retinaopathy of Prematurity (ROP – a potentially blinding condition) is detected.

Life-saving solutions are also being created specifically for use in the developing world, both by researchers in more developed regions and healthcare providers working in-country. These appropriate technologies are often designed with an eye towards sustainability, and make use of the skills of local craftsmen with readily available materials. Diagnostic technology is one area that holds great promise for creating technologies that are both highly effective and inexpensive, and that will provide a global benefit. Additionally, prosthetic and wheelchair fabrication techniques, such as those developed by the Center for International Rehabilitation (CIR) provide low-cost alternatives to standard prosthetic and orthotic devices that can be used in areas where resources or highly-trained personnel may not be available.

These technologies, initially conceived for use in medically underserved and post-conflict areas, also have the potential to impact healthcare in the developed world. The World Health Organization (WHO) reports that chronic disease is now the major cause of death and disability worldwide. With issues like cardiovascular disease, diabetes, and obesity, as well as pandemic outbreaks of H1N1 and HIV/AIDS, the development and utilization of globally appropriate solutions is surely practical. Hector Casanova, CP and Yeongchi Wu, MD, both iCons in Medicine Members, have noted the importance of exploring these technologies as possible alternative treatment options to help lower healthcare costs while maintaining a high quality of care. To this end, many technologies that have been conceived for use in the developing world are now being applied in the United States as well in a process known as “reverse innovation.” Companies like General Electric have created technologies in emerging markets and then bringing them to more developed regions.

Through “reverse innovations” and the application of appropriate technologies conceived in the developed world for the developing world or for global application, healthcare worldwide can be improved. By utilizing appropriate technologies that best combine the task at hand with the technological, cultural, and economic framework of the region where they are deployed, connections can be forged to make high-quality medical knowledge available around the globe.

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The WHO Report on Global Women’s Health

The World Health Organization (WHO) recently released a comprehensive report entitled “Women and health: today’s evidence tomorrow’s agenda.” The report documents the difficulties that women worldwide face when seeking healthcare at all stages of life. Findings in the report indicate that though women live six to eight years longer than men, on average, they often lack essential healthcare throughout their lives.

According to Reuters, women seek medical services more often than their male counterparts, especially before, during, and after pregnancy. In addition, women in the United States pay approximately 48 percent more than men for healthcare services. The report discusses the fact that in many nations “sexual and reproductive health services tend to focus exclusively on married women,” therefore assistance during childbirth can be particularly difficult to access for “unmarried and marginalized women, teenagers and sex workers.” Further, the WHO report notes that 99 percent of the estimated 500,000 women who die during childbirth each year are in the developing world where there is an extreme shortage of medical supplies and trained healthcare providers.

The Boston Globe reports that 15 percent of deaths in adult women worldwide occur in maternity, and one in five deaths among women in this age group is linked to unsafe sex. The WHO report indicates unsafe sex, stemming from the dearth of information regarding safer sex strategies and contraception, has also contributed to the spread of HIV and other sexually transmitted infections. In sub-Saharan Africa, one in four women who wish to delay or stop bearing children do not use any family planning methods, according to the WHO. A National Public Radio (NPR) report indicates that HIV is the number one killer of women ages 15 to 49 worldwide. Further, in 2007, 15.5 of the 30.8 million global cases of HIV-positive adults were women. Reports indicate that the largest portion of these individuals live in Africa, where six percent of women of childbearing age have the disease. NPR reports that, per the CIA World Factbook, half of the women ages 25 to 29 in Swaziland are infected with HIV – a small nation with a total population of one million people, 26.1 percent of whom are HIV-positive.

Women in resource-limited regions are at a particular disadvantage, as these areas often lack access to screening and treatment resources for diseases like cervical cancer, the second most common type of cancer in among women. A study of the introduction of the HPV vaccine published in the New England Journal of Medicine in 2007 stated “Of 274,000 deaths due to cervical cancer each year, more than 80% occur in developing countries, and this proportion is expected to increase to 90% by 2020.” Complications related to pregnancy, including unsafe abortion procedures, are among the leading causes of death among girls aged 15 to 19 in developing nations. Though these issues are substantial concerns in middle- and high-income nations, the WHO report indicates that road traffic injuries are the leading cause of death in girls between the ages of 10 and 19 in these regions. Among women over the age of 60, chronic diseases account for almost half of the deaths worldwide, and cardiovascular disease – generally considered a “male disease” – is the primary cause of death for this age group.

Discussing the importance of the comparative women’s health report, Dr. Margaret Chan, director-general of the WHO, said “The obstacles that stand in the way of better health for women are not primarily technical or medical in nature. They are social and political…It’s time to make sure that women and girls get the care and support they need to enjoy a fundamental human right at every moment of their lives, that is, their right to health.” The overview statement for the report echoes this sentiment, explaining that “we will not see significant progress as long as women are regarded as second-class citizens in so many parts of the world…women are excluded from educational and employment opportunities…and have no freedom to spend money on health care, even if it means saving their own lives.”

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Mobile Medical Apps

New technologies, both mobile and Internet-based, hold potential medical applications that may advance care. Through cellular telephones, netbooks, and laptops, physicians and healthcare providers are now able to utilize these technological improvements at the point of care. Non-profit organizations, research teams at universities, and other groups are working to develop applications for use on cell phones, often with integrated web-based features, to ensure that medical knowledge is fully accessible worldwide.

Web-based iConsult, the flagship program of the iCons in Medicine initiative, allows for collaboration between healthcare providers worldwide through a teleconsultation software and social networking website. The iConsult application, which functions like email, is easy-to-use, reliable, and designed for use in areas with limited or intermittent connectivity. The system facilitates knowledge transfer worldwide by pairing Volunteers, medical specialists who lend their expertise, with Requestors, medical professionals who work for non-profits in remote or medically underserved areas. Through the software and website, Volunteers and Requestors may collaborate on difficult medical cases from a distance, providing specialty advice that otherwise might not be available. Volunteers in the iCon Network who elect to take part in iConsult agree to provide at least three teleconsults per year. The iConsult software allows Requestors to upload a case consultation form, including digital images, and discuss potential diagnoses and treatments on a one-to-one basis with Volunteers in a secure environment. Other organizations, like InSTEDD (Innovative Support to Emergencies Diseases and Disasters), develop free and open source technologies to enable seamless and reliable collaboration between individuals working in the developing world and areas affected by conflict situations or natural disasters. GeoChat is a mobile communications service designed to allow for group communications via cellular telephones and online. The technology can be used in humanitarian crises to ensure that individuals who may be trapped, injured, sick, or in need of assistance can be reached quickly and their needs addressed. Unlike platforms that are only web-based, InSTEDD’s GeoChat allows healthcare providers and others to form a team and use SMS messaging, email, and/or a web browser to share information based on their location, providing an accurate documentation of conditions in a given region.

In addition to web-based initiatives, many organizations have begun developing and distributing applications for smartphones, creating a new base of information for both physicians and the general public. An analysis published by Manhattan Research in February 2009 indicates that more than 10 million adults in the United States use mobile devices to access health information. This figure may include individuals who chose to purchase the Merck Manual Home Health Handbook (3rd Edition) in its iPhone application format. Users can reference a range of health topics on-the-go with this and other similar applications. The Merck Manual is available in both a home and professional edition, and features a search engine and the ability to bookmark and email subjects. Other organizations, such as health insurance company Medica, are making efforts to increase the public’s awareness about healthcare and its costs through iPhone applications like Main Street Medica. The application, which is available to all consumers, not only Medica members, offers users the chance to compare the cost of common procedures at hundreds of clinics and facilities.

Though some look for health information on their own, a recent Opinion Research Corporation survey found that 64 percent of consumers turn to their physicians for health advice and feel that they are their most trusted source of health information. In an effort to ensure that healthcare providers have up-to-date information, organizations like Emerging Solutions in Pain (ESP) have also begun releasing mobile applications intended for use by medical professionals. ESP has launched an application for healthcare professionals involved in pain management or addiction medicine called ESP Mobile, which provides multimedia information in a mobile format and also includes up-to-date information and educational programs in pain management, news articles, and clinical support resources for providers. Physicians at Houston-based Memorial Herman Healthcare System use this and a number of other iPhone applications, including Airstrip OB, which displays medical notes and real time vital statistics of women as they approach delivery. The thousands of doctors and nurses within the 11 hospitals that comprise the System also utilize apps in the emergency room to quickly identify medications – particularly useful “if an unconscious patient comes in with a pocketful of pills.”

Other applications may be of use to both physicians and patients including language translation applications and a number of websites and mobile applications developed to provide up to the minute disease outbreak tracking and evaluation. Primarily focused on the medical community, applications like the Arabic Language Buddy, which provides real time, two-way English-Arabic translation; and Jibbigo, which converts English to Spanish and vice versa, offer potential tools for doctors working in regions where they are not fluent in the native language. Websites developed by the United States government and a joint effort from Microsoft Corp. and Emory University are more focused on providing patients with information, and may help individuals determine if their symptoms indicate possible H1N1 virus infection and warrant a doctor visit. Outbreaks Near Me, a mobile application for the iPhone developed by researchers at the Children’s Hospital of Boston, provides real time tracking of the spread of H1N1 infection. IntuApps application Swine Flu Tracker provides similar information as well as maps and “threat level” indicators.

Both mobile applications and web-based tools provide a chance to share information and knowledge across borders and ensure that quality medical care is delivered worldwide. New innovations continue to flood the marketplace, and it remains to be seen what the next improvement in healthcare technology will bring.

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On the Uses of Stem Cells

Though their use remains controversial, new research and innovative procedures indicate that stem cells may be applicable in more situations than previously thought. Stem cells are immature cells with the ability to grow into any type of tissue. Scientists have worked for years to perfect methods of extracting and directing these cells to grow into different tissue types to heal injuries and cure diseases. In addition to human embryonic stem cells (hESCs), methods of using patient specific cells in regenerative medicine are being refined. Like embryonic stem cells, induced pluripotent stem cells (iPS cells) have the potential to become any type of cell in the body. Because iPS cells are made by “rewinding” adult cells to their pluripotent state – a state from which they can grow into other types of tissue – they can be created from a patient’s own tissues, thus lessening or eliminating the risk of rejection. According to the Los Angeles Times, iPS cells could be used to grow insulin-producing beta cells for patients with diabetes or nerve cells for patients with spinal cord injuries.

Using this type of “adult stem cells,” researchers at the Wayne State University School of Medicine have developed a procedure to increase mobility and quality of life for patients with spinal cord injuries. The process involves the use of progenitor cells from a patient’s own nasal tissue, thus lessening the chances of rejection, tumor formation, and disease transmission sometimes experienced when using donated tissue. Twenty patients with severe chronic spinal cord injuries took part in the Wayne State University study, led by Associate Professor Jean Peduzzi-Nelson. Each received a treatment of partial scar removal in combination with transplantation of nasal tissue and physical rehabilitation. Results from participants, including one paraplegic individual who is now able to ambulate with two crutches and knee braces, indicate that the transplantation of nasal tissue (an “olfactory mucosal autograft”) is an effective and safe treatment for individuals with chronic spinal cord injuries.

Other types of adult cells have also been used for transplantation to damaged tissues. At the Cincinnati Children’s Hospital Medical Center, fat stem cells from a 14-year-old boy were used to form cheekbones that the young patient lacked. This new technique has the potential to benefit approximately seven million people in the United States, including individuals with various forms of cancer, and those injured in conflict situations. A section of bone from a donated cadaver was shaped to resemble zygomatic bones and act as a support structure for the growth of new tissue. Mesenchymal stem cells from the patient’s fat and a growth-encouraging protein were injected into holes in this bone base. Before implantation, the research team wrapped the grafts in periosteum tissue, which helps encourage stem cells to produce bone tissue. Stem cells were harvested from fat tissue as they exist in similar proportions as in bone marrow tissue, but do not require invasive procedures to gather them.

Using embryonic stem cells from mice, researchers have been able to successfully create a “heart patch” to repair damage caused by heart disease. Bioengineers at Duke University created a 3D mold and used it to grow heart muscle cells or cardiomyocytes. In addition to the mold used to ensure that the cells would not grow as a disorganized mass, cardiac fibroblasts, which comprise up to 60 percent of the heart, were added. These cells helped to guide the growth of the patches and properly align the cells so that they would have properties similar to heart tissue. The heart patches created displayed critical features of heart muscle – the ability to contract and to conduct electrical impulses.

Studies indicate that transplants using pigment-containing visual cells derived from hESCs have also had some success. In individuals who underwent these procedures, structure and function of the light-sensitive lining and the eye (retina) were preserved. For millions who lose their sight or experience low-vision, this type of cell-replacement procedure could prove beneficial. Jennifer Elisseeff, associate professor in biomedical engineering at Johns Hopkins University, and her team have also utilized stem cells to repair damaged and deteriorating knee cartilage. In addition, Elisseeff’s team is working to enable stem cells to reconstruct muscle and fat lost during surgery or trauma and developing an eye patch constructed of special biomaterial derived from collagen to help repair damage to a patient’s cornea.

The use of hESCs remains controversial, though the Obama administration has lifted Bush-era restrictions on federal funding for research based on their use. iPS cells offer an alternative that may prove as beneficial or more so as there is no risk of rejection of the transplanted tissue. For patients with spinal cord injuries, deteriorating vision, compromised heart function, and many other health concerns, treatments using stem cells may offer an opportunity to heal that would otherwise not be available.

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The Flu Vaccine

As new cases and concerns about seasonal flu and swine flu (H1N1) continue to spread worldwide, two vaccines have recently been made available. Both the nasal spray vaccine and injectable vaccine for seasonal flu have proven effective for specific portions of the population, however distribution is still slow. For the H1N1 (swine flu) virus, The Baltimore Sun reports, availability is still an issue and many areas have not yet received enough doses to meet the demand. While many in the developed world do not yet have access to the H1N1 vaccine, Dr. Bernadine Healy notes that the problem is even greater in the developing world. To help these nations fight the pandemic, the United States has agreed to donate 10 percent of its vaccination supply to the World Health Organization (WHO) – eight other nations will make similar donations.

Inoculating individuals for both viruses is complicated by the time frame in which the vaccinations can occur. If one chooses nasal spray for both seasonal and swine flu, they must wait four weeks between doses, while if one is injected for one virus and uses nasal spray for the other, they can be administered together. Discovery Health reports that doctors recommend annual flu shots to lessen the chances of becoming ill. Individuals as young as six months can be inoculated, according to the Centers for Disease Control and Prevention (CDC) and side effects are reported to be minor. Because the virus used to make the seasonal flu vaccine is dead, it is not possible to contract flu from a flu shot, however one may expect a low-grade fever 8 to 24 hours following injection, a swollen or tender area around the injection site, a slight headache or chills within 24 hours.

The seasonal flu shot is an inactivated vaccine, and contains three influenza viruses – one A(H3N2) virus, one regular seasonal A(H1N1) virus (which differs from the 2009 H1N1 virus), and one B virus. The viruses used change annually based on international surveillance which track infection trends and scientists estimations about which strains will circulate during the year. In contrast to the flu shot, the nasal-spray flu vaccine contains a weakened but still living flu virus, sometimes called LAIV (live attenuated influenza vaccine). These nasal mists are approved for use in healthy individuals ages two to 49 who are not pregnant. In addition to nasal sprays, Discovery Health reports that researchers at Stanford University and the University of Alabama at Birmingham have been working with naked DNA in an effort to develop a vaccine that could be delivered via shampoo or dermal patch.

Three recent large-scale studies, including a study led by Dr. Arnold S. Monto of the University of Michigan, indicate that while the seasonal flu shot is more effective for adults and safe for women who are pregnant, the intranasal vaccine (nasal spray) is more effective at preventing flu in children. These studies showed 35 to 53 percent fewer cases of flu in children who were given the nasal spray vaccine than those who received injected vaccines. The Los Angeles Times reports that injectable vaccines prevent roughly 50 percent more seasonal flu in healthy adults than the nasal spray vaccines.

Due to the relative newness of the H1N1 vaccine, health authorities have implemented a number of tracking measures to ensure its safety. The Associated Press reports that Harvard Medical School scientists are working to link insurance databases covering 50 million people with vaccination registries to allow them to determine if people visit a doctor after being vaccination as well as the reason for the visit. Johns Hopkins University and the CDC are also working to ensure that any side effects are noted and addressed quickly. These efforts include emailing individuals who have been vaccinated recently to see how they are feeling (Johns Hopkins), and preparing take-home cards asking vaccine recipients to report any side effects to the nation’s Vaccine Adverse Event Reporting system (CDC). These measures are being undertaken as in the Internet-age, the Associated Press notes, one person updating their Facebook status to say that they got a flu shot and feel sick could cause a wave of similar reports.

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Associated Press on the Nasal Spray Flu Vaccine – The New York Times on CDC Side Effect Tracking Measures

The Price of a Soda

Obesity-related illnesses account for nearly 10 percent of all medical spending in the United States – an estimated $147 billion each year. Recent reports and study findings indicate that excess consumption of soda and other sugary beverages may be contributing to America’s increasing weight. New York City Health Commissioner, Thomas A. Farley told the Epoch Times that “Drinking beverages loaded with sugars increases the risk of obesity and associated problems, particularly diabetes but also heart disease, stroke, arthritis and cancer.” Initiatives have been launched to help cap consumption, including a public awareness advertising campaign in New York City and proposed taxation on sugary beverages, but their success has yet to be documented.

CNN reports that sugary soft drinks contribute about 10 percent of the calories in the American diet. An “Extra Large” 32-ounce Coke contains 400 calories, nearly a quarter of the caloric total required by an average adult woman each day. Researchers at the University of North Carolina at Chapel Hill analyzed the national beverage consumption patterns of over 73,000 individuals over two years of age and found that between 1977 and 2001, overall calories from sweetened beverages had increased 135 percent. Findings from the UCLA Center for Health Policy Research and the California Center for Public Health Advocacy indicated that 62 percent of children ages 12 to 17 and 41 percent between 2 and 11 consume at least one sugar-sweetened beverage daily. The same UCLA study also found that adults who consumed one or more sweetened beverage each day were 27 percent more lightly to be overweight or obese.

Wayne Campbell, professor in the Department of Foods and Nutrition at Purdue University, explained that the human body does not react in the same way to solid and liquid calories, making these “sugar bombs” particularly problematic. A mix of hormones control appetite, ghrelin being the one that signals that it is time to eat again. When a large meal is consumed, ghrelin levels drop for several hours, however this does not occur when a large quantity of a sugary beverage is taken in. According to Harvard endocrinologist Dr. David Ludwig, the sugars in soda are rapidly absorbed, “which raises blood sugar and in effect causes the body to go into panic.” Insulin is released to break down the sugar, “but the body overcompensates, and blood sugar drops below the fasting level.” In response to low blood sugar levels, ghrelin and other hormones are secreted, triggering hunger and causing an individual to consume more.

According to Dr. Harold Goldstein, over the last 30 years, Americans consume at least 278 more calories daily, though physical activity levels have remained the same. Dr. Goldstein explained that during that period, soda and other sugary beverages accounted for as much as 43 percent of the new caloric intake. An American Heart Association survey indicated soft drinks comprised the top source of “discretionary sugar calories.” According to their findings, women should consume no more than 100 calories of added processed sugar per day (6 teaspoons), and men should limit their intake to 150 calories (nine teaspoons). Just one 12-ounce soda can contain as much as 13 teaspoons of sugar, often in the form of high fructose corn syrup, compounds of which researchers at Rutgers University say may start a chemical chain reaction leading to diabetes.

In an effort to raise awareness about the potential health concerns of drinking too much soda, the Fund for Public Health in New York has provided funding for an advertising campaign. The ads, which will run on 1,500 subway cars for three months, feature images of soda and other drinks becoming human fat as they are poured from bottles. “Are you pouring on the pounds?” the ads inquire, urging consumers to consider water or milk as alternatives to soda in order to not “drink [themselves] fat.” In the same vein, public health officials and U.S. health experts are calling for increased taxes on sweetened soft drinks. A study appearing in the New England Journal of Medicine cited research on the price elasticity of soda, indicating that for every 10 percent rise in price consumption declines 8 to 10 percent. Thirty-three states currently have sales taxes on soft drinks, but these existing taxes are viewed as too minor to affect consumption levels, and unlike the proposed tax initiatives, are not earmarked for health-related programs.
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Reuters on Soda and Obesity And Soft Drink Taxes – CBS on Soda’s Impact on America – NBC New York on Soda and Obesity – New York Times on New York’s Anti-Soda Ads And Proposed Taxes