Monday, September 28, 2009

Info Gathering is a Skill

I have two MPH student interns. This morning they were shocked to learn that my investigator has an MS, not an MPH. An MS in counseling psychology with no formal education in public health.

To be an epi investigator, you have to be able to talk to people. Crunching numbers is all fine and well, but you have to collect the data to begin with. My investigator has a background in crisis counseling. Perfect for this job. Because most people we are in contact with are in crisis. They have just found out they have a strange illness they may never have heard of, and the health department is calling them, asking questions. All most people know of this is what they've seen on TV, which we know is not always accurate. Having a background in crisis counseling helps my investigator calm the person down, provide some education, and get the information needed for the investigation.

In much public health work, we rely on people to give us information, willingly. It is all voluntary. People can (and do) hang up on us, or not even answer the phone. To do this job, you need to be skilled in social interaction. I am not that great on the phone with patients, which is why I have someone to do that for me. I am, however, pretty good at talking with docs, nurses, school administrators, mosquito control folks, sanitarians, etc.

A while back I had an intern who thought she was good with people. What she did, rather, was suck up to people. "Oh, Dr G, that is sooooo interesting!" "I'm sooooo impressed with people who have their PhDs!" I couldn't stand her. We both knew it was bullshit, so why bother?

I'm talking about being real with people. Don't treat them like they should give you the info you want just because you're you. And don't try to schmmoze people -- they see right through it.

This is a skill that most of the MPH students I interact with don't seem to have. I would say it is just a lack of working experience on their part, but I know these skills can be taught. I learned more about how to gather data from my qualitative methods courses in grad school than I ever did in the quantitative courses. The MPH programs I have worked with are so quantitative oriented, that they are missing that qualitative skill set.

Wednesday, September 23, 2009

Texas Hosptial Overflow Has Patients in Tents

A children's hospital in Austin has set up tents to deal with the mass numbers of kids coming to the ER. Most are mildly to moderately sick with the pandemic H1N1.

So far today I have received 5 reports of H1N1 hospitalizations. Prior to this, since April I only had 14. Glancing through the reports, the illnesses do not appear to be terribly serious. None of these 5 were in ICU or in need of ventilation. One was admitted for severe dehydration. Two were asthma exacerbation. One was a pregnant woman. The other one had significant underlying health conditions.

Surveillance shows an incredible amount of influenza-like illness in my area. I take the numbers with a grain of salt, though. Awareness is very high -- let's face it, it's tough to get away from "swine flu" messages right now. Combine that with fear. I suspect (and have in some cases been told) that school nurses are being very cautious with sick kids and reporting them as ILI when they might not have in the past. I also think that due to the hoopla people are more likely to seek health care now that usually. While demand has increased in some of the ERs, the overall level of hospital admission with serious illness is low. To me, the real signal to the severity of this pandemic will be severe illness and death.

Think of the common cold. How many of us get the common cold? I catch one or two cold viruses without fail each winter. Get myself a nasty sinus infection. I typically do not go to the doctor. But if I had reason to believe a particular cold might be something to get alarmed about, I might seek medical attention even though I did not need it. That would be a fear-driven response rather than a needs-based one.

Every time we have a highly publicized outbreak, many more people seek medical attention than would normally. Plus, when there is a highly publicized outbreak, docs are more likely to test for it. Some patients will demand the test even when the doc doesn't really have a medical reason for doing so. I heard about an ER fight this summer where a patient screamed for the test even though they didn't meet the lab criteria for testing, and there was no diagnostic reason for doing so. The poor ER doc ended up collecting a specimen which the lab promptly discarded. During the last peanut butter outbreak, people called me wanting to "get tested" because they felt sick to their stomachs. In our litigious society, many of these want to get in on the eventual class-action lawsuit. Still others like the novelty of saying they had the "peanut butter salmonella" or whatever else is going around.

Someone told me the other day that his kid has "The H." We all decided that sounded cooler than H1N1.

I am not advocating complacency, but rather reasoned caution. I'll keep an eye on severity (heck, H1N1 is all I ever do any more). We'll all wash our hands, because, let's face it, it will stop lots of germs from infecting our bodies. We'll all cough in our sleeves and we'll all stay home when we are sick. And the vast majority of us will be just fine. I wonder if one day this will all be looked upon as the 2009 Y2K, with senate hearings on the vast amounts of money being spent on pandemic control.

Thursday, September 17, 2009

The Flu Queen

Yesterday I gave a presentation to a grassroots community coalition about flu. Today I am presenting at a hospital. This afternoon I am presenting to a group of school nurses. I spend all day, every day, dealing with flu. A colleague has dubbed me the Flu Queen and my investigator the Flu Princess and promises to have us both sparkly tiaras soon.

The good news on the flu front is that data from the pandemic H1N1 vaccine are starting to spill out. The New England Journal of Medicine had several articles on trails. In terms of safety, the reports are mild side effects, the kind expected when you give any shot -- sore arm, in some cases fever. There was also reports of headache. Nothing alarming. No sentinel events. The FDA has approved the vaccine both in shot and nasal spray. Lots and lots of doctors will be giving the shot, so it looks like most people will just be able to go to their primary care physician to get it, or to a pharmacy or doc-in-the-box. If they can't get it there, they can get it from their health department.

In other news, a case of cysticercosis was reported the other day. A guy was in a bar fight, ended up in the ER. They did a CAT scan of his head due to the injuries, and lo and behold, there were worms in his brain. Nothing delusional about them. That's a bad Friday night out.

Monday, September 14, 2009

H1N1 Conspiracies

This weekend someone sent me a link to this video. It is the wackiest H1N1 conspiracy theory I have heard yet. I looked up the claim that Oklahoma is mandating the vaccine -- they aren't. And while health departments across the nation are receiving and exorbitant amount of money to administer H1N1 vaccine, there are no plans of blockades, checkpoints, or non-removable metal bracelets. At least not that I am aware of. And considering that if such plans were in place, I would be one of the government workers administering them, I am fairly confident that we can all calm down.

I think that some people truly want the worst-case scenario, The Postman, Dies The Fire, Y2K, post-apocalyptic scenario to happen. The survivalist fantasy is exciting. The copy repair man who becomes a military leader after the power goes out, the librarian who becomes a hero. That notion that we could be more in the right circumstances, if only we weren't caught in the tedium of day to day lives, working to pay off the mortgage, car loans, and credit cards. Let's erase everything and start over.

I'm afraid H1N1 isn't it.

Friday, September 11, 2009

Delusions of Parasitosis

Imagine, for a moment, that you have a crawling sensation on your arm. You scratch at the itch, and it seems to go away. A short time later it returns, and you find yourself scratching at it again. You examine your arm for the cause and find what look like small insect bites.
The next day, your arm is itching again. This time you cannot find relief, and your back begins itching as well. The itch distracts you throughout your day, and towards the end of the evening you ask a friend to look at your back. She says it is a bit red, but otherwise she doesn’t see anything. That night as you try to sleep, you feel something crawling across your skin. You turn on the light, but find nothing.

In the morning you find that you have scratched so much that whelps have scabbed over. Bits of white debris are on the spot where your arm itches. When you examine the debris closely, you see that it looks like tiny insects. You realize with a touch of horror that you are infested with some sort of bug. You place the carcasses into a small plastic container and make an appointment with your doctor.

You explain the situation to your doctor. He sees you scratching, sees the discomfort you are in. He examines you, and examines the bugs in the container. Unbelievably he tells you there is nothing wrong with you. “Those are not bugs at all,” he says. “It is bits of your skin.” He claims it is all in your mind.

Delusional Parasitosis (DP), also known as Ekbom’s Syndrome, was first described in the medical literature in the 1800s. Patients complained of parasitic infestation, however, no physical evidence of that infestation could be found. The infestation was, in fact, all in their minds. A delusion. A hallucination.

Patients with DP most often describe that insects are crawling, biting, and/or burrowing in their skin, although there have been reports of delusional intestinal parasitosis and DP of the oral cavity. In their delusion, many patients will actually “see” the parasite, and can describe, and even draw, the insect in great detail. Many will bring their physicians containers of matter they say is from the bugs. This behavior is so common that it is known as the “matchbox sign,” i.e. debris is carried to the doctor in a matchbox. Upon evaluation, however, the matter is often small bits of human skin or hair, or other fibers.

To rid themselves of the insects, patients will often impart in elaborate purification rituals, which often lead to self-mutilation. They may apply pesticides or disinfectants to the skin, and will often scratch themselves to bleeding. They may cut into the skin in an attempt to remove the parasites. One study describes a patient who tried to remove the parasites using a blowtorch. Changes in the skin, such as excoriation or lichenification, are typically observable, particularly on the scalp, face, and hands. Occasionally the condition leads to suicide.

Two variants of DP are described in the literature. Primary DP occurs in the absence of any underlying disorder. There is nothing wrong with the patient -- aside from the delusion. DP may also be secondary to other conditions, including schizophrenia, depression, and dementia, as well as other physical disorders, such as diabetes mellitus, renal insufficiency, hepatitis, vitaminB12 deficiency, multiple sclerosis, or leprosy. DP may also be induced via use of drugs, for example amantadine, anticholinergic agents, levodopa, and occasionally by some antibiotics, as well as recreational drugs, such as crystal methamphetamine and amphetamines. DP is so common among cocaine users that it is referred to as “cocaine bugs” by cocaine users.

Most DP patients share the following characteristics: (1) They are likely to exhibit slightly paranoid or obsessive-compulsive behaviors, (2) have difficulty expressing anger or hurt feelings, (3) have difficulties forming close relationships, and have limited social networks, (4) they may be predisposed to skin conditions which cause varied sensation responses, (5) they are likely to live in impoverished conditions, and (6) they may have underlying sexual impulses or thoughts which them deem to be “filthy” or “unclean.” Overall however, their mental status is stable.

Onset of DP has been reported following traumatic events (such as death of a loved one), after flooding of one’s home, travel, injury, and after contact with persons with an actual insect infestation (i.e., lice, scabies); however, DP does not necessarily include a recognizable precursory event.

DP takes a significant toll on the patient’s life. Patients will express significant concern about infecting others, and will take steps they feel will prevent this from occurring. Shared delusions, known as folie á deux or folie á famille, have been reported. Some studies suggest this phenomenon occurs in as many as 25% of DP cases. In this case, one or more household members of the DP patient reports infestation. Typically, the initial patient is the mother – who is often a dominating family force. They will often consult a number of different healthcare providers of many different specialties, as well as pest control professionals and entomologists. Ultimately, much time, money, and effort are expended in an attempt to get rid of the bugs. Frustration will mount, and feed into a perception that no one wants to help them. Despite the quest for assistance, however, DP patients generally refuse psychiatric intervention. The suggestion that the problem is one of the mind reinforces the aforementioned feelings of abandonment by the medical community.

A key issue in terms of treatment is the general refusal of DP patients to seek psychiatric help. The delusion is real to them – they truly believe they are infested with parasites – therefore to refer them for psychiatric evaluation is to further reinforce their belief that the healthcare practitioner does not care about their suffering.

The incidence of delusional parasitosis is difficult to determine due to lack of reporting and the variety of health care practitioners consulted. One study estimated seven in 10,000 psychiatric admissions were related to DP. A 2007 study of dermatologists found that 85% of the doctors in the study had observed patients at some point in their practice with DP.

In cases associated with substance abuse, patients are more likely to be young adults of marginalized socio-economic status. In contrast, DP patients without history of substance abuse are more likely to be over age 50. DP seems to affect older women at a higher rate than older men. A 1978 study of 57 DP patients described a mean age of onset at 64 years of age and a predilection for women (74%). Other characteristics included a history of mental retardation, folie á deux, underlying chronic disorder (such as dementia and diabetes) and additional underlying psychiatric disorders. Two of the patients in this study reported history of suicide attempt.

A 1983 survey of dermatologists also found that women were more likely to exhibit DP, particularly when over age 50. This survey also noted underlying chronic conditions such as diabetes and hepatitis, as well as psychological disorders, including depression and schizophrenia. A similar survey of dermatologists in 1986 found older women more likely to present with DP. This was supported yet again in a 1990 study in which 82% of the patients were women.

Seasonality has been described in the literature. One researcher conducted a long-term survey of telephone consultations of persons suspected of having DP with the Mississippi health department and cooperative extension offices. Over an eight year period, he found DP to be more prevalent during the late summer and early fall. Interestingly, most of the calls I have taken like this occur in the spring. The weather warms up and the DP cases increase.

It is important to rule out actual insect infestation or allergens before beginning other treatments, as well as to explore co-morbidities or behaviors (i.e. drug abuse) which may be causing the delusion (as in secondary DP). While a physical cause for the patient’s symptoms may not be found upon examination, the suffering of DP patients is intense, real, and clearly visible. Interviewing techniques that include empathy and relationship-building are repeatedly emphasized in the literature.

It has been suggested that many health care professionals who treat DP patients may not have the specific expertise to effectively manage the patient’s psychological needs, and dermatological training that covers psychodermatoses may be beneficial. For dermatologists and others who encounter DP patients in their offices, it is helpful to have an established relationship with a psychiatrist for referrals of patients willing to see one. In some instances, it may be possible for the psychiatrist to evaluate the patient in the dermatologist’s office. A liaison that can smoothly transition the patient between dermatological care and psychiatric care can also be beneficial.

Due to the negative side effects of neuroleptic DP treatments, health professionals may find it useful to determine which patients could develop insight into their condition over time. There is some discussion in the literature of patients presenting with “shakable” as opposed to “fixed” (true delusion) beliefs about the parasites. This is an important distinction in terms of treatment. Studies have demonstrated that some DP patients hold shakable beliefs, and will agree that they perhaps are not infested when presented with ample evidence to the contrary. For these patients, talk therapy, as well as treatment of any underlying disorder, is indicated. The therapist should empathize with the patient’s condition and accept that the patient truly is in distress; however, to agree that the patient is actually infested only furthers the delusion.
Material brought by the patient (the matchbox sign) should be examined. The therapist should explain what the specimen actually is (fibers, bits of skin, etc). The therapist should review the negative laboratory studies with the patient and explain their meaning, and remind the patient that no medical professional has been able to validate their claim. Patients with shakable beliefs, may, when confronted with enough evidence, accept that they are not infested. Some patients will continue with their delusion regardless of evidence presented.

DP is a condition which a variety of healthcare workers, public health professionals, veterinarians, and etymologists may encounter in their practice. The condition has significant impact on the lives of those who suffer from it. When confronted with a DP patient, a compassionate response is indicated. One should empathize with the patient without feeding in to the delusion, and demonstrate scientifically (when feasible) that there is no rational basis for their claim. Preexisting relationships with mental health providers may facilitate getting patients proper treatment and alleviating much suffering.


Wednesday, September 9, 2009

Kids in School, Spreading Flu

I never intended for this to become an influenza blog, yet it does seem to be trending in that direction, doesn't it? I suspected flu levels would increase when school started back up, but Boy Howdy. I wasn't quite prepared for the onslaught.

The question should not be who has flu, but rather who doesn't have it. A school in my city almost closed because so many kids were out sick yesterday. This wasn't a disease control issue, but rather a financial one -- 26% of the kids were absent.

I have a pretty intensive surveillance system for influenza-like illness in the schools. Levels right now mimic those that I typically see at the beginning of seasonal epidemics.

The hopeful news is that this may burn through the population, peak, and level out to usual flu activity. My prediction is that we see an early peak in the next month or two, followed by a peak in seasonal flu in February, and then in subsequent years H1N1 just becomes another strain in the usual circulation, we call swine the new seasonal and we are done with it. I hope I'm right on that one. I feel like H1N1 has taken over my life. It's all I do at work anymore. And I think my spouse may have it.