Healthtips

West Nile Virus

By Kelby Bethards, MD

Well, it’s that time of year again unfortunately. The skeeters are out and biting their aggravated victims. As of right now, Larimer County has 3 confirmed cases of West Nile Virus (WNV) and 1 from as early as late May. This is a full month and a half earlier than the first case last year. I thought it would be a good idea to get out some information to the community, since there will be illness due to this virus again this year. Hopefully not as much, but we’ll see. I will go over some of the facts about the virus, about the sign and symptoms of the illness and about what we (medical profession) do about it.

Basic facts:

- First discovered in America in New York in 1999. We aren’t sure how it got here, but it is virtually identical to the virus particle in Israel . Originally, there was concern that it could be a weapon, but that doesn’t seem very likely now. Especially since it isn’t very effective.

- The virus particle’s primary vector (mode of transport) is birds. That’s how it cruised across the country so fast.

- It has now been reported in 47 states. Only 3 left to go.

- It, obviously, is passed to humans by mosquitoes. It has a bird-mosquito-bird mode. Humans and horses are incidental hosts.

- Nearly all human disease (West Nile Fever) is via mosquito bites, however, transmission from transplanted organs, transfused blood and transplacentally has been noted. Transmission via breast milk is also possible.

- Human to human (contagious) spread doesn’t happen other than the afore mentioned ways.

Signs and Symptoms:

- Incubation period: 3-14 days after a mosquito bite, the first signs may appear.

- Most human cases (80%) are not clinically evident. No symptoms.

- Of the other 20%, most people have a febrile (with fever) illness.

- West Nile Fever consists of: Fever (75%), malaise or tiredness (85%), headache (85%), myalgias or muscle aches (75%), muscle weakness (72%), chills (66%), loss of appetite (68%), rash (63%), eye pain (49%) and swollen glands (39%). Some patients get transient (passing) muscle twitches and tremors, and some have had paralysis that did reverse.

- The worst part of the illness and symptoms lasts a week or so, but the fatigue can last several weeks.

- Severe disease occurs in 1% or less of the population (that’s why it wouldn’t be a very good weapon). This usually only happens to very young children and people over 65 yrs old. Consists of: Paralysis, seizures, encephalitis (brain infection), meningitis (brain lining infection), and the subsequent consequences of having these more serious infections.

Treatment:

- Nothing. Sad but true. That is an understatement (or maybe an overstatement I don’t know) in that we do try our best to treat all the symptoms and sequelae (problems from the infection). BUT, it is a virus and we do not have treatments for viral illnesses, generally speaking.

- Like I mentioned we do try to treat the facets of the illness, which we call supportive care. If people have pain we try to treat the pain, if they have seizures, we give them anti-convulsants, if they have respiratory failure, we “hook” them up to a respirator, etc.

- Unfortunately, it is a wait and see illness, and so we wait and see what symptoms arise. But, fortunately, most people do not become very ill with it.

- There has been some trials of antibody and antiviral therapy, but we aren’t sure that it helps yet.

Testing:

- We do basic lab work to help us make sure that it is WNV, but there are a few actual WNV tests available for the blood and cerebral fluid.

- These tests are expensive and not being subsidized by the health department this year.

- The tests will most likely be upward of 160 bucks.

- My “protocol” is to only test the people sick enough to be hospitalized, but we can order it if the patients want to pay for it.

- Caveats: If the patient has been immunized for yellow fever or Japanese encephalitis the test may be a false positive. Also, patients that have had Dengue fever or any of the class of flaviviruses (class of virus that WNV belongs to), may also test false positive. Conversely, a patient test positive for WNV and actually have a different illness. Especially since 80% of WNV infections don’t have any symptoms.

Other considerations:

- Once you have had it, you’ve had it. If a patient was to become re-infected, they already have the antibody’s (infection fighting artillery) against it.

- There are two types of mosquitoes, basically, that carry WNV Colorado. Of those two populations, one only seems to have 1/10 of the number compared with last year. The other type is at full force with equal numbers to last year.

- So what does that mean? Protect yourself. Long sleeves and pants, and use repellant when around mosquito infested areas.

More info: www.nchd.org and www.cdc.gov

Cancer Screening

With all the hub bub about cancer and various tests for cancers, I thought it’d be prudent to give some information and guidelines about the different types of cancer (most common types) and how we (medical community) go looking for them. We’ll start with the most common.

LUNG CANCER:

This is the number 1 killer of men and women in the USA , in terms of cancer. It was estimated that lung cancer killed 157,000 people last year. In perspective, breast, prostate, and colon cancers combined killed 126,000 people last year (estimated). So how do we screen? The answer as ungratifying as it may be, is that we don’t screen for lung cancer. IT IS NOT THAT WE HAVEN’T TRIED. There have been numerous attempts to use our current tests available to detect it early. We just have not been able to find or design a way to test for lung cancer that changes the outcome.

What I mean by this is that even if we had a test and found that a patient has lung cancer, by the time we catch it, we can’t do a thing about it. Now, that is a generalization, but in essence, we don’t help people live much longer after we know the cancer is there.

What are the risk factors? As we know, smoking is responsible for 87% of lung cancers. So that is the major risk factor. Recently more research has gone into second hand smoke and it is know to be a risk factor also. The other risk factors, which are far less common, are exposure based. These include exposures to asbestos, nickel, haloethers, hydrocarbons and arsenic.

Message: To lower the risk of lung cancer, STOP SMOKING. Because, even if we find lung cancer, more than likely, we can not treat it.

BREAST CANCER:

This is the number 2 killer of women, cancer wise. Although the experts don’t necessarily agree on the best screening methods, there are some general guidelines that most of us follow. It was estimate that 211,000 new cases of breast cancer were found in 2003. And, breast cancer was estimated to cause more than 40,000 deaths (0.1 % of those were men). There are projections that somewhere between 1 out every 6 to 1 out of 9 women will develop breast cancer. SO, screening is very important.

Screening tests: Breast exams (self and by physician). Mammography. This is where the experts don’t necessarily agree. I will put the most conservative recommendations here and it is important for you to discuss your individual needs and health with your health care provider to decide what to do.

Mammograms: Every one to two years starting at age 40, then yearly from 50 – 69. This is a point the experts don’t agree on. Some say start at 50. Most recommend stopping at age 70.

Breast Exam: Women should do self-exams starting at age 20. This should happen monthly on the same day, related to your menstrual cycle. Health care providers will generally start doing these every 2 to 3 years starting at age 20. Again, there is not a consensus on this. Some experts say don’t start exams until age 40.

Ok, now for the risk factors. We know that breast cancer affects different age groups differently: From age 1 to 39 the risk is 1/235. From 40 to 59 the risk is 1/25. From 60 to 79 the risk is 1/15. The overall lifetime risk for women is 1/8 that they will develop breast cancer.

Interestingly, the differences in race are negligible throughout the USA , but there are state to state variances. Women of higher socioeconomic class and in urban areas are at higher risk. It is believed that this has something to do with the number of children they have (less) and that they have children at a later age.

The age at which women begin having periods (later is better) and the age at which women have menopause (earlier is better) are also involved.

Family history is very complex. We aren’t certain if the environment that people live in as compared with there relatives play a role or not. We DO KNOW that there are genes involved however. BRCA1 and BRCA2 are the genes most talked about and are very strongly associated with breast cancer. Moral of the story, IF A FIRST DEGREE RELATIVE (mother, father, siblings) had breast cancer the risk increases significantly for the other family members.

Density. Increased breast density is a risk for breast cancer. This actually have more to do with our ability with exams and with mammography to detect a cancer.

Estrogen. Geesh, this is in the news a lot. Estrogen is implicated in breast cancer. Both endogenous (from within the body) and exogenous (for example: pills) estrogen have been shown to increase breast cancer over long periods of time. SO WHAT ABOUT BIRTH CONTROL PILLS? Nope. They, usually, have progesterone with them which have a protective effect.

Now, there is a lot more to breast cancer than presented here. These are generalities, so if this raises questions, come see us. Each person and case is different and should be evaluated differently.

PROSTATE CANCER:

This is the number 2 killer of men, cancer-wise, in the USA . 220,000 new cases were expected in 2003. And, the anticipation was that prostate cancer would cause 38,900 deaths in 2003. The lifetime risk of men developing prostate cancer is 16% and the risk of dying from it is 3%. Interestingly, in an autopsy series, 1/3 of men autopsied had evidence of prostate cancer under the age of 80 and 2/3’s of men autopsied older than 80 have an incidental finding of prostate cancer. What does this mean? It means, in general, that prostate cancer is very slow growing and usually men die from something else.

Screening: We use about four methods to look for prostate cancer. We start with the PSA blood test and the DRE (rectal exam). If we have concerns based on either or both of these tests, we send the patient to the urologist to have prostate ultrasound or possibly a biopsy. Of course, the experts don’t agree on the best ways or ages to do these tests or which to do. It is generally recommended that screening start at age 50 (some say 40). UNLESS, a first-degree relative had prostate cancer (father, brother), then we begin earlier.

Risk Factors: Prostate cancer doesn’t usually occur in men under 45 years of age, but can. The incidence increases sharply after that age. African American males are at a higher risk. And as mentioned if a first-degree relative had prostate cancer, the risk for an individual is doubled. Here is a an interesting point, the breast cancer genes, BRCA1 and BRCA2 are implicated in prostate cancer. This means, that if a first-degree relative had breast cancer that was genetic, the men have an increased risk of prostate cancer.

Now, there are a lot of smaller, possible, risk factors which I won’t list here but feel free to ask us.

COLORECTAL CANCER:

For both men and women this is the third most common cancer. Estimates were that 148,000 new cases were discovered in 2003 and that it would claim more than 57,000 lives. Of the 148,000 new cases, 106,000 were in the colon and the other 42,000 were rectal cancers.

Screening: Fecal Occult Blood Test, FOBT (ie blood hidden in the stool) every year. These are the little cards we send you home with for the fun task of sending them back to us with a sample. Sigmoidoscopy every 3 to 5 years, beginning at age 50. OR, colonoscopy every 10 years beginning at age 50. Some groups of experts suggest a double contrast barium enema instead of the colonoscopy (that doesn’t seem to be the current standard).

Risk Factors: Now, this list can be long. I will include the most common ones and we can answer questions for you at the clinic if specific concerns arise. Heredity plays a role. There are many familial syndromes where people grow polyps (Familial Adenomatous Polyposis is an example) in their colon. This is usually different, however, from the person that goes in for a coloscopy and a benign polyp is found at age 50. These people generally have polyps and a very young age.

BUT, having had a polyp does put a person at increased risk of colon cancer also. This gets a bit more complicated yet. Large polyps (greater than 1 cm) or a type that we call villous (sort of finger like, but many of them), carry a 3.5 to 6.5 of becoming cancerous.

People with inflammatory bowel disease, such as Ulcerative Colitis, are at an increased risk of colon cancer. There is evidence now also that diabetics have an increased risk also for colon cancer. Alcohol consumption is also linked to colon cancer but to what extent isn’t determined yet. Other risk factors we know do exist: cigarette smoking, prior pelvic radiation therapy, and low and behold the BRCA1 (breast cancer gene) also predisposes someone to a greater chance of colon cancer.

Its not all bad news though, there are protective factors out there. The biggest protective factors for colon cancer are a diet high in fruit and vegetables, regular exercise, regular use of antiinflammatories (Aspirin and NSAIDS, such as ibuprofen) and in women, post-menopausal hormone replacement therapy.

Along those same lines, a diet low in red meat, low in animal fat and low in cholesterol seems to reduce the risk of colon cancer significantly. High fiber and the supplemental use of folic acid, calcium, and vitamin D are all protective factors.

Of course the rules all change if a first degree relative has had colon cancer. SO, make that if that is the case, you let us know, so we can decide when to start screening.

CERVICAL CANCER:

It was estimated that there were 13,000 new cases of cervical cancer in 2003, and over 4000 deaths from this cancer last year. This cancer we are doing better with all the time. Rates and deaths from cervical cancer are on the decline and have been declining steadily over the past several decades.

Screening: This one more “expert” groups agree on. Most agree that screening should begin with Pap smear tests EVERY YEAR starting at age 18 or at the onset of sexual activity. Now, most doctors don’t do this, but screening can be spread out to every 3 years, once a woman has had 3 normal pap smears in a ROW (three years worth) and is in a stable, monogamous relationship. ANYTIME, partners change or an abnormal is found, the screening goes back to the yearly tests. As many woman out there know, the next step after the abnormal pap smear is the colposcopy (microscope visualization of the cervix). Why to we do this? The Pap smear is not a diagnostic test, it tells us something is possibly wrong, but not what is wrong. The colposcopy, with biopsies, helps us further clarify the diagnosis after an abnormal pap.

Risk factors: We know that certain types of HPV (Human Papilloma Virus, the same class virus that causes warts) are very causative in this cancer. There are whole boat load of HPV viruses, and we know which strains seem to be more dangerous, so for some people we do the HPV testing. How do we get HPV. Well, that opinion is different amongst doctors. We do know that it is sexually transmitted and that it tends to affect the male much less. BUT, cervical cancer from these different virus strains has been found in nuns too. SAFE SEX, obviously, is the way to cut down on the spread of the virus, but some people would say, its everywhere.

SKIN CANCER:

Now this one is very important in Colorado and especially in the rural areas where farming is prominent. In other words, SUN EXPOSURE, is the key to this one. Melanoma, the most prominent malignant skin cancer, rates are on the rise. Estimates show that over 54,200 new cases would be found in 2003 and 7600 died from melanoma.

Screening: This one is easier to screen for, if it is done. Recommendations are that full body skin exams are done every 3 years from ages 20 to 40 and yearly after age 40. Also, patients can monitor themselves for it. We, the doctors use the nomogram ABCDE:

A-Asymmetry – Irregular shapes, not oval or round.

B- Border irregularities – Borders that fade or aren’t smooth.

C- Color variation – Different colors in the same mole or lesion.

D- Diameter greater than 6 mm – About the size of a pencil eraser.

E- Enlargement – If the mole or lesion continues to grow.

So, if a lesion is concerning, we biopsy it. If there is any suspicion, we biopsy it.

Risk Factors: As I mentioned, the sun is the usual culprit. More on that. It’s not just sun exposure, it is repeated, sporadic, intense sun exposures. It is suspected that having just 5 bad sunburns as a kid increases the risk of skin cancer by double. The other skin cancers, like squamous cell carcinoma, is caused by long term, cumulative sun exposure.

Genetic factors do play a role. Red head, blondes and people with fair skin, blue or green eyes are at increased risk. People who don’t tan well are at risk. And, people with a lot of moles.

Tan beds: Sorry, they do increase the risk of skin cancers.

Well as you can probably tell, these thing are fairly complex to sort out, even for us doctor folk. SO, IF YOU HAVE QUESTIONS, that is good, you should have questions, so contact us. Everybody’s case is different and we need to tailor the screening and care to the specific circumstances. So, come visit us and we can answer questions that you may have.