Kissing Bugs and Heart Disease: Identifying Chagas’ Patients

By Ajay K. Singh, MBBS, FRCP, MBA
April 18, 2017

In managing patients with heart disease, most of us do not think about the possibility of Chagas’ disease (CD). CD is estimated to affect 5 million people worldwide and according to CDC seroprevalence estimates, affects about 300,000 people. CD accounts for nearly five times as many disability-adjusted life years lost as malaria. CD is estimated to cause approximately 7000 deaths annually.

A recent study by Sheba and colleagues of a convenience cohort of 4,755 Latin American-born residents of Los Angeles County reports that 1.24% tested positive for CD.

Bern and colleagues provide a comprehensive review of CD.  The disease was discovered in 1909 and is named after the Brazilian physician Carlos Chagas; Chagas’ is also known as American trypanosomiasis.

The protozoan parasite Trypanosoma cruzi (T. cruzi) is the cause of CD. It is thought that immigrants from Latin American countries acquire the trypanosomal infection from transmission by insect vectors (carried in the gastrointestinal tract of triatomine bugs) found in impoverished rural areas of Latin America. Triatomine bugs are also known as “kissing bugs”  because they bite while a person is asleep around the thin skin of the face around the eyes and mouth. T. cruzi transmission occurs when infected bug feces contaminate the bite site or intact mucous membranes, but it can also be transmitted through transfusion, via a transplanted organ, and congenitally.

CD has both an acute and chronic phase of disease. The acute phase is either asymptomatic, or associated with fever in a subset of patients with a chagoma. These chagomas contain the parasite and present with swelling and inflammation at the site of inoculation. Acute CD can rarely also present with more severe myocardial and central nervous manifestations.

[Review HMS lectures on Current Trends in Cardiology.]

The chronic phase manifests either with cardiac or digestive disease. Cardiac CD is a cardiomyopathy characterized by a chronic inflammatory process involving all chambers, conduction system damage, and a progressive dilated cardiomyopathy with congestive heart failure. Patients may also present with thromboembolism due to thrombus formation in the dilated left ventricle or aneurysm. Gastrointestinal CD disease is less common than cardiac CD and geographically distinct (mostly detected in Argentina, Bolivia, Chile, Paraguay, Southern Peru, Uruguay, and parts of Brazil rather than northern Latin America, Central America, or Mexico) and usually affects the esophagus and/or colon, resulting from damage to intramural neurons.

So what are the implications from the Sheba study? Sheba and colleagues make several recommendations. First, the prevalence of CD in the US has been underestimated and more awareness is necessary. Indeed, the US Center of Disease Control (CDC) considers CD, along with as cysticercosis, toxocariasis, toxoplasmosis and trichomoniasis, as a neglected parasitic infection.  Second, earlier diagnosis and treatment of CD might significantly impact the morbidity and mortality of the disease. And, third screening strategies should be considered for individuals at high risk: Latin American immigrants from endemic areas would be at the top of the list for screening. Indeed, screening tests are available for CD. Besides these, while CD is more common among immigrants, it has been detected in native-born Americans underscoring the importance of considering CD in the differential diagnosis of a cardiomyopathy.

Ajay Singh, MBBS, FRCPDr. Ajay K. Singh is the Senior Associate Dean for Global and Continuing Education and Director, Master in Medical Sciences in Clinical Investigation (MMSCI) Program at Harvard Medical School. He is also Director, Continuing Medical Education, Department of Medicine and Renal Division at Brigham and Women’s Hospital in Boston.

*OPINIONS EXPRESSED BY OUR AUTHORS ARE VALUABLE TO US AT LEAN FORWARD, BUT DO NOT REPRESENT OFFICIAL POSITIONS OR STATEMENTS FROM HARVARD MEDICAL SCHOOL.

If President Trump Cuts NIH Funding, We All Lose

Photo caption: Youngmi Ji, Ph.D., research fellow, conducts research in the NIAMS Cartilage Biology and Orthopaedics Branch. The lab’s research focuses on understanding specific orthopaedic pathologies to better facilitate clinical translation of lab results to medical therapies.

By Ajay K. Singh, MBBS, FRCP, MBA
March 21, 2017

Adrienne Lafrance writing in the Atlantic:

“The work of a scientist is often unglamorous. Behind every headline-making, cork-popping, blockbuster discovery, there are many lifetimes of work. And that work is often mundane. We’re talking drips-of-solution-into-a-Petri-dish mundane, maintaining-a-database mundane. Usually, nothing happens.”

Lafrance continues: “Scientific discovery costs money—quite a lot of it over time—and requires dogged commitment from the people devoted to advancing their fields. Now, the funding uncertainty that has chipped away at the nation’s scientific efforts for more than a decade is poised to get worse.”

The recent budget proposed by the Trump administration, if passed, will cut the NIH budget by nearly 20%. This will most certainly affect both intra- and extramural NIH funding. Since about 80% of NIH’s funding is extramural, the impact on research institutions around the country will be devastating. Still, even more demoralizing is the potential effect on individual researchers. The figure below shows that the success rate for NIH funding is currently less than 20%. If the Trump budget plan prevails, the funding rate will plummet even further. Promising research will not get done.

NIH Funding graph

If this cut was not bad enough, the Trump budget seeks to shut down the NIH’s Fogarty International Center. While the budget of the Fogarty Center is relatively small  (≈69 million dollars), it’s mission is important at a time of emerging global infectious threats: funding training programs in global health and supporting global projects that include research into HIV/AIDS, Ebola, and Zika.

In a statement introducing the budget, Mick Mulvaney the director of the Office of Management and Budget, says “I am proud to introduce the ‘America First’ budget.”

Cutting funding for the NIH is not placing America First.

If American science loses, the country loses. Slashing NIH funding destabilizes science all over the country – institutions will lose precious support from indirect funding, and investigators will not receive direct funding for promising projects, which will likely be terminated in the thousands. Crucial infrastructure will be dismantled. And, young people aiming for a career in bench or clinical science, will have their dreams dashed.

The cut in funding will destabilize science and everything science stands for at a very critical juncture. It will take our eyes off the prize – of curing disease and relieving human suffering. And, it will send a message to the rest of the world, that America is readying itself to give up as the world’s leader in science.

This is not enhancing America’s security. This is not putting “America First.”

[NIH photo credit:
National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health]

Ajay Singh, MBBS, FRCPDr. Ajay K. Singh is the Senior Associate Dean for Global and Continuing Education and Director, Master in Medical Sciences in Clinical Investigation (MMSCI) Program at Harvard Medical School. He is also Director, Continuing Medical Education, Department of Medicine and Renal Division at Brigham and Women’s Hospital in Boston.

*OPINIONS EXPRESSED BY OUR AUTHORS ARE VALUABLE TO US AT LEAN FORWARD, BUT DO NOT REPRESENT OFFICIAL POSITIONS OR STATEMENTS FROM HARVARD MEDICAL SCHOOL.

Marijuana Use: The National Academy Report

*OPINIONS EXPRESSED BY OUR GUEST AUTHORS ARE VALUABLE TO US AT LEAN FORWARD, BUT DO NOT REPRESENT OFFICIAL POSITIONS OR STATEMENTS FROM HARVARD MEDICAL SCHOOL.

By Ajay K. Singh, MBBS, FRCP, MBA
Tuesday, January 24, 2017

The use of marijuana for medical treatment is legal in 28 states and the District of Columbia (DC). And recreational marijuana (or pot) has been legalized in eight of those states and DC.

Marijuana is derived from the dried leaves, flowers, stems, and seeds from the hemp plant, Cannabis sativa. Delta-9-tetrahydrocannabinol (Delta-9-THC) is the primary psychoactive ingredient in marijuana.

The January 12, 2017 publication of the report, “The Health Effects of Cannabis and Cannabinoids: The Current State of Evidence and Recommendations for Research” by the blue ribbon National Academies of Sciences, Engineering and Medicine in Washington, D.C. provides some important information on the risks and benefits of marijuana.

The report is available online and is very well worth a read. Highlights (excerpted) include:

Therapeutic Effects

  • In adults with chemotherapy-induced nausea and vomiting, oral cannabinoids are effective antiemetics.
  • In adults with chronic pain, patients who were treated with cannabis or cannabinoids are more likely to experience a clinically significant reduction in pain symptoms.
  • In adults with multiple sclerosis (MS)-related spasticity, short-term use of oral cannabinoids improves patient-reported spasticity symptoms.
  • For these conditions, the effects of cannabinoids are modest; for all other conditions evaluated, there is inadequate information to assess their effects.

Cancer

  • The evidence suggests that smoking cannabis does not increase the risk for certain cancers (i.e., lung, head, and neck) in adults.
  • There is modest evidence that cannabis use is associated with one subtype of testicular cancer.
  • There is minimal evidence that parental cannabis use during pregnancy is associated with greater cancer risk in offspring.

Psychosocial

  • Recent cannabis use impairs the performance in cognitive domains of learning, memory, and attention. Recent use may be defined as cannabis use within 24 hours of evaluation.
  • A limited number of studies suggest that there are impairments in cognitive domains of learning, memory, and attention in individuals who have stopped smoking cannabis.
  • Cannabis use during adolescence is related to impairments in subsequent academic achievement and education, employment and income, and social relationships and social roles.

Mental Health

  • Cannabis use is likely to increase the risk of developing schizophrenia and other psychoses; the higher the use the greater the risk.
  • In individuals with schizophrenia and other psychoses, a history of cannabis use may be linked to better performance on learning and memory tasks.
  • Cannabis use does not appear to increase the likelihood of developing depression, anxiety, and posttraumatic stress disorder.
  • For individuals diagnosed with bipolar disorders, near daily cannabis use may be linked to greater symptoms of bipolar disorder than non-users.
  • Heavy cannabis users are more likely to report thoughts of suicide than non-users.

The 16-member National Academy committee comes to the following conclusion, “There is conclusive or substantial evidence that cannabis or cannabinoids are effective:

  • For the treatment for chronic pain in adults (cannabis)
  • Antiemetic’s in the treatment of chemotherapy-induced nausea and vomiting (oral cannabinoids)
  • For improving patient-reported multiple sclerosis spasticity symptoms (oral cannabinoids)

[Develop your skills in clinical research for CME credit st HMS Global Academy.]

Ajay Singh, MBBS, FRCP

Dr. Ajay K. Singh is the Senior Associate Dean for Global and Continuing Education and Director, Master in Medical Sciences in Clinical Investigation (MMSCI) Program at Harvard Medical School. He is also Director, Continuing Medical Education, Department of Medicine and Renal Division at Brigham and Women’s Hospital in Boston.

*OPINIONS EXPRESSED BY OUR AUTHORS ARE VALUABLE TO US AT LEAN FORWARD, BUT DO NOT REPRESENT OFFICIAL POSITIONS OR STATEMENTS FROM HARVARD MEDICAL SCHOOL.

 

Substance Use Disorder: The Surgeon General’s Report

By Ajay Singh, MBBS, FRCP
November 21, 2016

A quote from Chris Prentiss’s book1, The Alcoholism and Addiction Cure is an appropriate backdrop to the publication this past week on The Surgeon General’s Report on Alcohol, Drugs, and Health.

Writes Prentiss about addiction: “It’s the causes, not the dependent person, that must be corrected. That’s why I see the United States’ War on Drugs as being fought in an unrealistic manner. This war is focused on fighting drug dealers and the use of drugs here and abroad, when the effort should be primarily aimed at treating and curing the causes that compel people to reach for drugs.”

Surgeon General Vice-Admiral Dr. Murthy asks the question: “How we respond to this crisis is a moral test for America.”

In my view the Surgeon General’s Report is a “tipping point” in changing our knowledge and perception about substance abuse.

Time and again the report states “addiction is a health condition, not a moral ailing or character flaw

The full report2 and executive summary3 are available online.

Some Highlights:

  • More than 27 million people in the US reported using illegal drugs or abusing prescription drugs in 2015.
  • There are over 20 million people in the country with substance use disorders, which is approximately the same number of people with diabetes, and 1.5 times the number of people with all cancers combined.
  • Only 1 in 10 people with substance abuse disorders are receiving treatment.
  • In 2014, over 43,000 people died from drug overdose, more than in any previous year on record.
  • Substance abuse must be identified in general health settings, including primary, psychiatry, and emergency care.
  • Effective screening will help create individual treatment plans.
  • Treatment is critical and effective.
  • More than 25 million individuals with a previous substance use disorder are in remission and living healthy, productive lives.
  • Increasing access to medicine—methadone, buprenorphine, and naltrexone—is crucial to fighting the opioid crisis.
  • Substance abuse treatment is not just the work of individual specialists. A mix of caregivers should treat it—social workers, recovery specialists, and nutritionists—just as they do with diabetes or cancer. 

Post-script

The word “malarkey” came to mind after reading an opinion piece4 by Dr. Manny Alvarez’s about the Surgeon General’s Report. The full definition of the word “malarkey” in the Merriam-Webster dictionary is  “insincere or foolish talk”.


The Opioid Use Disorder Education Program

The Opioid Use Disorder Education Program (OUDEP) is now available from HMS Global Academy. OUDEP is comprised of 3 free online CE/CME courses produced by Harvard Medical School (HMS) with scientific contributions from The National Institute on Drug Abuse (NIDA). These courses are intended for nurses, nurse practitioners, physician assistants, physicians, and other health care providers collaborating to treat patients with substance use disorders.


References

1Chris Prentiss C: The Alcoholism and Addiction Cure: A Holistic Approach to Total Recovery ISBN 0943015448 Published October 1st 2005 by Power Press (first published January 1st 2005)

2Department of Health and Human Services, Office of the Surgeon General, Facing Addiction in America: The Surgeon General’s Report on Alcohol, Drugs, and Health. Washington, DC: HHS, November 2016.

3Executive Summary

4Alvarez M: Dr. Manny: Surgeon General Murthy leaves legacy of too little, too late.  Accessed Nov 20, 2016

Ajay Singh, MBBS, FRCP

Dr. Ajay K. Singh is the Senior Associate Dean for Global and Continuing Education and Director, Master in Medical Sciences in Clinical Investigation (MMSCI) Program at Harvard Medical School. He is also Director, Continuing Medical Education, Department of Medicine and Renal Division at Brigham and Women’s Hospital in Boston.

*OPINIONS EXPRESSED BY OUR AUTHORS ARE VALUABLE TO US AT LEAN FORWARD, BUT DO NOT REPRESENT OFFICIAL POSITIONS OR STATEMENTS FROM HARVARD MEDICAL SCHOOL.