Medical Journal Review : ALLERGY

• Exploring the association between severe respiratory syncytial virus (RSV) infection and asthma (A).
  Does RSV cause A, or do those infants who later develop A have a genotype that both predisposes them to A and makes them more susceptible to severe RSV infection? That question is explored in this population-based study of hospitalization data from all Danish twins born alive between 1994 and 2000 (8280 twin pairs). The diagnosis of RSV infection was based on hospital diagnosis and/or RSV identification by ELISA. Presence of A was assessed by hospital discharge diagnosis and parental questionnaire. Among the children with RSV infections, 50% were hospitalized before the age of 6 mo and 75% before 12 mo. 95% had been hospitalized before 24 mo. Twins hospitalized for RSV were more likely to have A. The data were subjected to statistical analysis and direction of causation (DOC) modeling. Monozygotic twins showed a higher correlation for A than dizygotic twins, suggesting a genetic component in disease susceptibility; but for RSV there was no such correlation, meaning that environmental factors play a larger role. When data were fitted to a DOC model, it was found that the best fit occurred for RSV infection resulting from the underlying susceptibility to A rather than vice-versa.
  Editor’s comment: These data support the concept that RSV is associated with but does not cause A implying unknown genetic factors are involved.
  Thomsen SF et al., Am J Resp Crit Care Med 2009; 179:1091-1097. Also see editorial by Kuehni and Silverman, pp. 1079-80 (Abstract not available online)
• Urine concentrations of cysteinyl leukotrienes (CysLTs) in children with obstructive sleep-disordered breathing (SDB).
  Adenotonsillar tissue from children (C) with SDB shows high levels of CysLTs and their receptors that may contribute to this disorder. C with SDB were compared to C with no evidence of SDB but with a history of recurrent tonsillitis. Subjects with asthma, respiratory tract infection or chronic inflammatory disorders were excluded along with those using antihistamines or intranasal corticosteroids. An obstructive apnea-hypopnea index (OAHI) was determined by overnight polysomnography and tonsillar size graded. Morning urine samples were assayed for CysLTs. A total of 92 C were enrolled and results were evaluated according to OAHI. C with OAHI ≥5 episodes/hr had significantly higher urine CysLT levels than those with mild or no SDB. Higher BMIs and larger tonsils were also predictors of SDB. These data support the hypothesis that SDB is associated with inflammation as well as anatomical factors, but whether the SDB is more severe because of the increased CysLTs or severe SDB causes an increase in CysLTs cannot be determined.
  Editor’s comment: This study suggests that there is a link between SDB and inflammation.
  Kaditis AG et al., Chest 2009; 135:1496-1501.
• Venom immunotherapy (VIT) reduces large local reactions (LLRs) to insect stings.
  LLRs to Hymenoptera occur in 10% of adults and have significant effects on QOL, often requiring oral corticosteroids. This 4 yr controlled pilot study was performed to determine the effectiveness of VIT in reducing the severity of LLRs. Enrollees had a history of LLRs and skin sensitivity to venom. Those with previous sting anaphylaxis were excluded. A baseline sting challenge was performed at entry and only those with skin induration of at least 16 cm were included. 19 subjects (there were 10 untreated controls) achieved a maintenance dose in 7 weeks. Sting challenges were administered and patients recorded the size of induration at 1, 12, 24, and 48 hr after the sting. No additional medications (e.g., antihistamines) were allowed until 48 hr after the sting. The size and duration of LLRs decreased significantly with increasing time of VIT. Patient satisfaction was >90%.
  Editor’s comment: Several studies now indicate that VIT is effective to treat LLRs induced by Hymenoptera stings.
  Golden DBK et al., J Allergy Clin Immunol 2009; 123:1371-1375.
• Overweight and changes in weight status during childhood in relation to asthma (A) symptoms at 8 years.
  A symptoms in relation to body mass index (BMI) were assessed at 3, 6 and 8 yrs in a group of 3756 children in a birth cohort. Yearly questionnaires were returned by parents reporting the child’s weight and height and whether they had A symptoms- wheeze and/or dyspnea and/or a prescription for inhaled corticosteroids in the previous year. At age 8, a subgroup of children gave a blood sample analyzed for a panel of specific IgE. Bronchial hyperresponsiveness (BHR) also was determined. A high BMI at an earlier age was not associated with dyspnea in children who were at normal weight at 8 yr. Eight year-old children who had A symptoms and BHR were significantly more likely to have had a high BMI at 6-7 yr but not at earlier ages. IgE levels did not correlate with BMI.
  Editor’s comment: High BMIs in children at certain ages may be associated with the onset of asthma and BHR.
  Scholtens S, et al., J Allergy Clin Immunol 2009; 123:1312-1318. Also see editorial by Schwartzstein and Gold, pp. 1319-20.
• Work group report: oral food challenge (OFC) testing.
  This document is a comprehensive, practical guide to administering an OFC. The criteria for deciding when to conduct an OFC and the risk/benefit analysis are discussed with guidelines for skin-prick and serum IgE testing. The different types of OFC—open, single-blind, placebo-controlled and double-blind are described. An open OFC may be done for simple screening while the more rigorous DBPC is primarily for research. An OFC procedure form and flow sheet are included.
  Editor’s comment: This is a practical and highly useful document about OFC.
  Nowak-Wegrzyn et al., J Allergy Clin Immunol 2009; 123 (suppl):S365-383.
• Reparative capacity of airway epithelium impacts deposition and remodeling of extracellular matrix (ECM).
  Defective repair of damaged epithelium is linked to fibrosis and remodeling in chronic lung disease. This mouse-model study focuses on the interactions between epithelial repair systems and the regulation of ECM deposition and fibrosis. Epithelial lesions were produced by intraperitoneal injection of naphthalene and mice were examined from 0 (control) to 6 days afterwards. In repair-competent mice exposed to naphthalene, a specific phenotypic signature was seen representing airway repair, cell proliferation and ECM regulation. The ECM protein, tenascin C (Tnc), was transiently up-regulated in naphthalene-challenged wild type mice but returned to normal following epithelial repair. In mice deficient in epithelial repair cells, however, lung damage led to a significant and sustained increase in Tnc and uncontrolled matrix deposition. Lack of repair of damaged epithelium led to an accumulation of Tnc protein in the sub-epithelial mesenchyme of airways and alveoli.
  Editor’s comment: This study sheds additional light on the possible role of epithelial repair cells and Tnc in airway remodeling.
  Snyder JC et al., Am J Resp Cell Mol Biol 2009; 40:633-642.
• T-bet expression is regulated by EGR1-mediated signaling in activated T cells.
  T-bet is a transcription factor that polarizes T cell development along the Th1 pathway and suppresses Th2-type cytokine production and stimulates expression of IFN-gamma and the IL-12 receptor. Regulation of T-bet production by early growth response gene 1 (EGR1) was studied in this report using human B and T cell lines and T cells isolated from mice. EGR1 binds to the gene promoter for T-bet in T cells and activates its expression, while depletion of EGR1 in T cells prevents induction of T-bet. Naïve CD4+ T cells, isolated from mice and activated by antigen-presenting cells under Th0, Th1 or Th2 conditions, shows concomitant expression of EGR1 and T-bet in Th0 and Th1 cells but not Th2.
  Editor’s comment: EGR1 appears to be a key upstream regulator of T-bet expression.
  Shin H-J et al., Clin Immunol 2009; 131:385-394.
• Increases in urinary 9α,11β-prostaglandin F2 indicate mast cell activation in wine-induced asthma.
  Wine-sensitive individuals can experience asthmatic symptoms after wine consumption. 8 participants with self-reported wine sensitivity were tested with high- and low-sulfite wines given double-blind. As primary outcome, urinary 9α,11β-prostaglandin F₂ (a metabolite of prostaglandin D₂, PGD2) was measured before and after consumption. With high-sulfite wines versus low-sulfite wines, the 9α,11β-prostaglandin F₂ level increased 1.6- and 1.5-fold, respectively, demonstrating that sulfites probably are not linked to the asthmatic symptoms of wine consumption. PGD2 is elevated as a result of mast cell activation and urinary 9α,11β-prostaglandin F₂ is currently the most sensitive indicator of degranulation. It is more likely that IgE-indpendent activation of mast cells occurs based on clinical characteristics of these subjects.
  Editor’s comment: The reasons why wine may exacerbate asthma remain a mystery.
  Misso NLA et al., Int Arch Allergy Immunol 2009; 149:127-132.
• Desensitization in interferon-β1α (IFN-b) allergy: a case report.
  IFN-b is the standard Rx for relapsing-remitting multiple sclerosis (MS), but an immune response to the drug can occur preventing treatment. A 41-year-old female with MS diagnosed 15 months earlier presented with urticaria and angioedema after s.c. IFN-b. Urticaria and pruritus, not associated with the injection site, appeared after the first month of Rx and grew progressively worse until periorbital and perioral angioedema developed and the IFN-b was stopped. The urticaria cleared immediately with no relapse. Skin-prick and intradermal tests with IFN-b were positive for 1:1 and =1:1000 dilutions, respectively. A desensitization schedule with incremental alternating s.c. IFN-b injections every 30 min over a period of 4 days was performed. Desensitization was successful and the patient resumed IFN-b Rx 3X/wk with no adverse effects.
  Editor’s comment: This is a quick and simple desensitization procedure for immediate hypersensitivity to IFN-b.
  Kalpaklioglu AF et al., Int Arch Allergy Immunol 2009; 149:178-180.
• Inhibition of non-neuronal α7-nicotinic acid receptor for lung cancer treatment.
  Non-small cell lung cancer (NSCLC) tumorigenesis appears to involve nicotinic acetylcholine receptors (nAChRs). The effect of blocking the α7-nAChR with alpha-cobratoxin (α-CbT) was investigated on various human lung tumor cells and in nonobese diabetic/severe combined immunodeficient (NOD/SCID) mice engrafted with NSCLC cells. The proliferation of tumor cells in vitro was inhibited by α-CbT compared to normal bronchial epithelial cells and the degree of inhibition was proportional to the density of α7-nAChRs on the tumor cells. For the in vivo evaluation of α7-nAChR inhibition, NSCLC cells were injected into the lungs of NOD/SCID mice, allowed to grow for 7 days, after which they were treated with vehicle control, cisplatin (lung cancer chemotherapeutic agent) or α-CbT (i.v. injection 3 times/wk for 3 wks). The endpoint was length of survival from time of injection of the cells. Cisplatin improved survival 16% relative to controls, while treatment with α-CbT resulted in survival, 80% higher than cisplatin and 93% than controls. Assays on tumor cells from α-CbT-treated mice showed >80% apoptosis.
  Editor’s comment: This treatment offers promise as a way to slow the progression of NSCLC.
  Paleari L, et al., Am J Resp Crit Care Med 2009; 179:1141-1150. Also see editorial by ER Spindel, pp. 1081-82 (Abstract not available online)
• Bronchial airway epithelial cell damage following exposure to cigarette smoke (CS) includes disassembly of tight junction (TJ) components mediated by the extracellular signal-regulated kinase 1/2 (ERK1/2) pathway.
  CS is a mixture of many chemicals that have a variety of effects on airway epithelial cells, including changes in signaling pathways, such as those involving epidermal growth factor receptor (EGFR) and ERK1/2. CS condensate (CSC) was prepared by collecting CS particulates on a filter and dissolving the filtrate in cell culture medium. Cultured normal human bronchial epithelial cell lines were incubated with various concentrations of CSC and the effects on TJs, cytotoxicity, DNA integrity and ERK1/2 signaling were measured. CSC caused disassembly of tight junctions in a time- and dose-dependent manner. Decreased cell proliferation was seen only at the highest dose of CSC (20%) but apoptosis was seen at 10% and 20% CSC. Preincubation of cells with EGFR inhibitor blocked CSC activation of the ERK1/2 pathway and prevented both DNA fragmentation and disassembly of TJs.
  Editor’s comment: This in vitro evidence of ERK1/2 involvement in TJ damage warrants further study in animal models.
  Petecchia L et al., Chest 2009; 135:1502-1512.
• Acid-suppressive medication use and the risk for hospital-acquired pneumonia.
  Use of proton pump inhibitors (PPIs) or histamine-2 (H2) receptor blockers for controlling acid reflux has increased and are being given routinely to many hospital inpatients. All patients ≥18 yr of age admitted to a large metropolitan hospital with a stay of 3 or more days were eligible for inclusion in this prospective cohort study. Admission to ICU was excluded. The primary outcome scored was a discharge diagnosis of pneumonia and the final cohort included 63,878 subjects. Use of acid-suppressing drugs (82% PPIs, 23% H2 blockers, and some both) was ordered for 52% of the patients and use of PPIs (but not H2 blockers) was associated with a 30% increase in the odds of having pneumonia while in the hospital.
  Editor’s comment: Proton pump inhibitors may increase the risk for both inpatient and outpatient pneumonia.
  Herzig SJ et al., JAMA, 2009; 301(20):2120-2128.

More about → Medical Journal Review : ALLERGY

HGV - Hearts, Guts and Veins - Honey, Garlic and Vinegar

By Bruce Caine

Am I the only one that immediately thinks of 'Heavy Goods Vehicles' when I see the letters HGV? It's quite appropriate in a way as lorry drivers normally suffer more than most from weight problems - I had a number of truckers as patients and my advice was always the same: make time for exercise, eat more salads and cut out fried food in those road side cafés!

In fact, regardless of occupation, obesity and related cardiovascular conditions are the biggest killers in the western world!

Honey, Garlic and Vinegar capsules (HGV)!!!

Many doctors, nutritionists and homeopaths are excited about the enormously positive impact of this new weight loss product. It has also been specifically designed to naturally improve the health of the cardiovascular system, the intestines, bowel and generally to promote overall well being.

In addition to the experts' comments, are all the messages I received from our readers telling us just how quick acting and effective HGV really is (feel free to look at the readers' reviews section opposite). HGV genuinely doubles weight loss for the vast majority of people that use it as part of their daily dietary regime!!!

Funnily enough, in many medical circles (HGV) is known as 'Hearts, Guts and Veins' - an incredibly apt nick name!

So why Hearts, Guts and Veins?

When we are younger, losing weight is usually all about our own self image.

Our desire to appeal and look our best does not diminish with age. However, the fatal reality of a poor diet and weight problems become more and more frightening as we realise that our 'luck' will not last forever!

HEART- With excessive weight your heart suffers! It's a muscle and therefore has a limit on the workload that it can carry. Imagine every five years you keep adding an extra ten pounds of weight - at some point the heart is going to breakdown = Heart Attack!!!

GUTS - Extra weight almost always equals a poor diet. Our system is designed for a balanced diet of meat, vegetables and fruit. If your diet consists mainly of junk and fatty foods, excessive amounts of red meat and you do not include fruit and vegetables, then not only are you damaging your heart, you are also damaging your intestines and bowel. Cramps, regular bouts of gastro enteritis, constipation and diarrhoea, severe and constant haemorrhoids are all key symptoms of the intestines and bowel breaking down - this all increases the risk of stomach and bowel cancer.

VEINS - If the blood cannot pump normally into the heart because of clogged arteries, usually due to high cholesterol levels, it stops = Heart Attack!!!

These are the reasons why HGV is proving to be so effective and successful. It safely accelerates weight loss and helps you to maintain a healthy weight. It does this by ensuring improved circulation, healthy cardiovascular function and comfortable bladder and bowel activity!

Remakably, HGV capsules have also been proven to be highly effective in preventing and treating arthritis, bronchitis, prostatitis, psoriasis, rheumatism, and a variety of other conditions that are listed, just click below ....

Why is this combination recommended?

Important studies from respected universities around the world prove its a 'super way to fight just about any affliction'.

A study at the University of Illinois (USA) discovered that men aged between 18 and 68 could increase the antioxidant levels in their blood after drinking a couple of ounces of honey everyday for five weeks

A daily dose of garlic has proved to be a powerful fat destroyer and weight reducer, according to Dr. Raymond Fish of London's famous Obesity Research Center.

The prestigious British Medical journal, The Lancet, reported that cholesterol levels plunged on average from 237.4 to 221.4 after volunteers consumed 50 grams of garlic. The study proved the dangers associated with high fat foods can be neutralized by adding garlic to your diet.

"I have seen many arthritis patients start to loosen up at once", says Dr. Jack Soltanoff, a nutrition expert from New York praising the benefits of vinegar.

The benefits ofHGV can be summed up in a very simple way

HGV

Burns extra fat, Reduces production and storage of extra fat
Eliminates natural cravings for high fat foods
EFFECTS

Doubles weight loss as part of a calorie controlled diet
Lowers Cholesterol
Reduces high blood pressure
Increases energy and vitality
Promotes healthy bladder and bowel
Leads to better circulation
Significant reduction in depression
That's all for now - it's very hot here today so I'm going for a quick swim!

Keep smiling and stay healthy

Dr Bruce Caine is a Sixty Five year old retired GP, who is quietly losing his boyish good looks, but with dignity. I retired just over a year ago and the first six months were great - moving to Spain and doing all the things we've always wanted to do. But now, the truth is - I've started to miss being in practice and being involved with people. So, that's why I started The People's Doctor - a weekly newsletter all about general health matters. To learn more about Honey, Garlic and Vinegar Capsules visit my home page at http://www.thepeoplesdoctor.co.uk

More about → HGV - Hearts, Guts and Veins - Honey, Garlic and Vinegar

Historical Vignette - The Sad Case of Ignaz Semmelweiz, Part I

By Paul D Maher

In Vienna in the summer of 1846 a young Hungarian physician by the name of Ignaz Semmelweis had just been appointed to the post of assistant professor of Obstetrics at the Vienna General Hospital. There the young doctor found an appalling situation. His hospital ran two obstetric clinics which provided free perinatal care to the poor of the city. However, the clinic he was in charge of had a maternal mortality rate nearly 3 times that of the other hospital clinic and one which often exceeded 10% in any given month. Mind you this was not an infant mortality of 10%, rather one in ten mothers who entered this hospital to deliver a baby did not leave alive. It was so bad, the poor and the prostitutes of Vienna would often look to give birth on the street on the way to the hospital, in order to retain their child care benefits but not subject themselves to the potential health horrors of his clinic.

To Semmelweis' dismay, these "street births" as they were called did not suffer from the same risk of "child bed" or puerperal fever, the main cause of maternal death in his clinic, as those who were actually admitted to the clinic.

Being a contentious physician he sought the answer to this mystery stating the situation, "made me so miserable that life seemed worthless". One by one he eliminated various possible causes to account for the deaths of so many expectant mothers in his clinic, overcrowding, climate, medical technique and so forth were all examined and dismissed. The only difference he noted was that his clinic was used to instruct medical students while the clinic with much lower mortality was used to teach midwives. The mystery continued until somewhat later in 1847 when a good friend, Jakob Kolletchka, was pricked by a student's scalpel during an anatomy lesson with a cadaver. Over the ensuing days Kolletchka went on to suffer and die of an illness which very closely resembled the childbed fever so prevalent in the Vienna hospital. As Semmelweis stated,

"Day and night I was haunted by the image of Kolletschka's disease and was forced to recognize, ever more decisively, that the disease from which Kolletschka died was identical to that from which so many maternity patients died."
Puerperal fever in modern terminology would be recognized as a type of sepsis, an infection by bacteria seeded in the bloodstream. It began, as might be expected, with a high fever which usually came on quite suddenly and was accompanied by violent shaking chills. The infection was sometimes fought off and recovered from, however, if not, a condition of overwhelming sepsis ensued. The abdomen would often become unbearably tender to the touch. Only improving with a sometimes false sense of recovery when the abdominal tissue had become so gangrenous and necrotic as to be less painful. Over days or weeks, the bacteria and their toxins would attack every major organ system in the body. Even in modern times such a situation of overwhelming sepsis will quite often lead to death from multi organ system failure, the shutdown of kidneys, liver, lungs and/or endocrine system from the overwhelming infection. Without antibiotics the situation was generally a death sentence. And child bed fever sentenced women to die with a vengeance. Author Irving Louden in his "The Tragedy of Childbed Fever" estimates that in Europe of the 18th and 19th centuries, out of 1000 women in childbirth, 6-9 would contract the disease and 2-3 die of it. This background endemic rate was often punctuated by epidemic outbreaks where maternal mortality could exceed 50%. It was an ever present part of the fabric of society and described by a medical practitioner of the day as a "sort of desecration" that the relief and joy of successful childbearing would be followed so cruelly some days later by the onset of the disease.

Following the death of his friend, Kolletchka, Semmelweis observed that many of the medical students serving his clinic would go straight from their anatomy lessons with the cadavers to the maternity ward. Midwives, however, were not instructed in anatomy through the dissection of cadavers. In 1847, one year after being put in charge of the clinic, Semmelweis instituted a policy that we would only consider commonsense today, that of antiseptic handwashing before each delivery. The results he achieved using a solution of chlorinated lime as an antiseptic were dramatic to say the least. In April of 1847 the maternal mortality rate was 18.7%, hand washing was instituted in the middle of May. In June the mortality rate was 2.2%, in 1848, there would be two months with a zero death rate.

Perhaps at least, or even more, astonishing then the results Semmelweis achieved with his antiseptic approach was the response of the medical community of his time to his findings. Unfortunately his findings did not fit the prevailing wisdom of the day, which prescribed disease to an imbalance of humors often best treated through blood letting. Indeed, nearly a century before Semmelweis, noted Scottish obstetrician, Alexander Gordon, had correctly concluded that puerperal fever was spread by physicians and midwives, and that it had some relation to skin infections. In fact the staphylococcal and streptococcal bacteria responsible for the deadly childbed fever could sometimes be seen as a mild dermatological infection on the skin, a condition known as erysipelas. Despite his clear headed analysis of the etiology of the disease, Gordon then unfortunately concluded that puerperal fever should thus be treated by aggressive bloodletting; over a pint for an initial measure.

Semmelweis' findings were publicized initially by his students who wrote the heads of respected maternity clinics throughout Europe with news of their success. They detailed their findings in the well known English Medical journal the Lancet as well as other medical journals throughout Europe. A few individuals recognized the significance of the findings, Ferdinand Von Hebra who edited a prominent Austrian medical journal and would establish the modern discipline of dermatology, commented publicly in his journal that Semmelweis' findings had a significance comparable to that of Edward Jenner's work in developing the small pox vaccine. For the most part however, tragically, Semmelweis' findings were not merely dismissed they were ridiculed.

In time, of course, Semmelweis would go on to be called the "father of antisepsis" and the "savior of mothers". However, his research was still some decades before Louis Pasteur's groundbreaking microbiological work would lead to the "germ theory" of disease. The idea that minuscule infectious cadaveric particles on the hands could account for disease was rejected as irrational by some and offensive by others. As Charles Meigs the respected Philadelphia Obstetrician commented at the time, "Physicians are gentleman... and gentleman's hands are clean". Other noted medical authorities of the day likewise criticized the findings with vehemence and declared them unscientific.

The ensuing controversy with all of its political uproar soon cost Semmelweis his position in Vienna and he was forced to take an unpaid honorary position as head of Obstetrics at a small hospital in Pest, Hungary. There he again initiated his antiseptic regime, subsequently only eight patients would die of childbed fever in his clinic in the next five years. Eventually, he was able to obtain a more respectable position as professor of obstetrics at the University of Pest. Once again maternal mortality declined dramatically. Despite this and despite finally publishing himself at this time his findings he was dismissed by the obstetrical community of Europe, his ideas described by one respected obstetrician as "naive" and the "Koran of puerperal theology".

Over time Semmelweis' railings against the established medical doctrine grew more strident, he became obsessed with puerperal fever, and increasingly depressed at the rejection of his work. His behavior also began to become erratic and inappropriate. It is unclear to what extent his rapid decline was a result of stress from the rejection of his ideas. Some speculate that he was evincing signs of the neurologic sequela of tertiary syphilis, acquired either from a prostitute he was reported to have been frequently seen with or as an occupational hazard, often seen at that time, from his work. Be that as it may, as his condition worsened his friend and former professor, Ferdinand von Hebra, arranged, without Semmelweis' knowledge, to have him involuntarily committed to an insane asylum. When Semmelweis realized, too late, what was occurring he attempted to resist his commitment. In the process he was severely beaten by the hospital guards. In a painfully ironic twist of fate, he died two weeks later when an infection from his wounds seeded his blood leading to overwhelming sepsis, the same condition, from which he protected so many of his patients. Ignaz Semmelweiz was 46 years old.

A physician who spent nearly ten years at the US Food and Drug Administration, Dr. Maher, has authored peer-reviewed articles for the medical literature, authored a chapter on the genomics of rare diseases for a text book of rare disease therapy and writes on his website on neglected questions of medical importance as well as pointing out historical medical fallacies. You may find more of his work at The Skeptic's Health Journal Club,

More about → Historical Vignette - The Sad Case of Ignaz Semmelweiz, Part I

Historical Vignette - The Sad Case of Ignaz Semmelweiz, Part I

By Paul D Maher

In Vienna in the summer of 1846 a young Hungarian physician by the name of Ignaz Semmelweis had just been appointed to the post of assistant professor of Obstetrics at the Vienna General Hospital. There the young doctor found an appalling situation. His hospital ran two obstetric clinics which provided free perinatal care to the poor of the city. However, the clinic he was in charge of had a maternal mortality rate nearly 3 times that of the other hospital clinic and one which often exceeded 10% in any given month. Mind you this was not an infant mortality of 10%, rather one in ten mothers who entered this hospital to deliver a baby did not leave alive. It was so bad, the poor and the prostitutes of Vienna would often look to give birth on the street on the way to the hospital, in order to retain their child care benefits but not subject themselves to the potential health horrors of his clinic.

To Semmelweis' dismay, these "street births" as they were called did not suffer from the same risk of "child bed" or puerperal fever, the main cause of maternal death in his clinic, as those who were actually admitted to the clinic.

Being a contentious physician he sought the answer to this mystery stating the situation, "made me so miserable that life seemed worthless". One by one he eliminated various possible causes to account for the deaths of so many expectant mothers in his clinic, overcrowding, climate, medical technique and so forth were all examined and dismissed. The only difference he noted was that his clinic was used to instruct medical students while the clinic with much lower mortality was used to teach midwives. The mystery continued until somewhat later in 1847 when a good friend, Jakob Kolletchka, was pricked by a student's scalpel during an anatomy lesson with a cadaver. Over the ensuing days Kolletchka went on to suffer and die of an illness which very closely resembled the childbed fever so prevalent in the Vienna hospital. As Semmelweis stated,

"Day and night I was haunted by the image of Kolletschka's disease and was forced to recognize, ever more decisively, that the disease from which Kolletschka died was identical to that from which so many maternity patients died."
Puerperal fever in modern terminology would be recognized as a type of sepsis, an infection by bacteria seeded in the bloodstream. It began, as might be expected, with a high fever which usually came on quite suddenly and was accompanied by violent shaking chills. The infection was sometimes fought off and recovered from, however, if not, a condition of overwhelming sepsis ensued. The abdomen would often become unbearably tender to the touch. Only improving with a sometimes false sense of recovery when the abdominal tissue had become so gangrenous and necrotic as to be less painful. Over days or weeks, the bacteria and their toxins would attack every major organ system in the body. Even in modern times such a situation of overwhelming sepsis will quite often lead to death from multi organ system failure, the shutdown of kidneys, liver, lungs and/or endocrine system from the overwhelming infection. Without antibiotics the situation was generally a death sentence. And child bed fever sentenced women to die with a vengeance. Author Irving Louden in his "The Tragedy of Childbed Fever" estimates that in Europe of the 18th and 19th centuries, out of 1000 women in childbirth, 6-9 would contract the disease and 2-3 die of it. This background endemic rate was often punctuated by epidemic outbreaks where maternal mortality could exceed 50%. It was an ever present part of the fabric of society and described by a medical practitioner of the day as a "sort of desecration" that the relief and joy of successful childbearing would be followed so cruelly some days later by the onset of the disease.

Following the death of his friend, Kolletchka, Semmelweis observed that many of the medical students serving his clinic would go straight from their anatomy lessons with the cadavers to the maternity ward. Midwives, however, were not instructed in anatomy through the dissection of cadavers. In 1847, one year after being put in charge of the clinic, Semmelweis instituted a policy that we would only consider commonsense today, that of antiseptic handwashing before each delivery. The results he achieved using a solution of chlorinated lime as an antiseptic were dramatic to say the least. In April of 1847 the maternal mortality rate was 18.7%, hand washing was instituted in the middle of May. In June the mortality rate was 2.2%, in 1848, there would be two months with a zero death rate.

Perhaps at least, or even more, astonishing then the results Semmelweis achieved with his antiseptic approach was the response of the medical community of his time to his findings. Unfortunately his findings did not fit the prevailing wisdom of the day, which prescribed disease to an imbalance of humors often best treated through blood letting. Indeed, nearly a century before Semmelweis, noted Scottish obstetrician, Alexander Gordon, had correctly concluded that puerperal fever was spread by physicians and midwives, and that it had some relation to skin infections. In fact the staphylococcal and streptococcal bacteria responsible for the deadly childbed fever could sometimes be seen as a mild dermatological infection on the skin, a condition known as erysipelas. Despite his clear headed analysis of the etiology of the disease, Gordon then unfortunately concluded that puerperal fever should thus be treated by aggressive bloodletting; over a pint for an initial measure.

Semmelweis' findings were publicized initially by his students who wrote the heads of respected maternity clinics throughout Europe with news of their success. They detailed their findings in the well known English Medical journal the Lancet as well as other medical journals throughout Europe. A few individuals recognized the significance of the findings, Ferdinand Von Hebra who edited a prominent Austrian medical journal and would establish the modern discipline of dermatology, commented publicly in his journal that Semmelweis' findings had a significance comparable to that of Edward Jenner's work in developing the small pox vaccine. For the most part however, tragically, Semmelweis' findings were not merely dismissed they were ridiculed.

In time, of course, Semmelweis would go on to be called the "father of antisepsis" and the "savior of mothers". However, his research was still some decades before Louis Pasteur's groundbreaking microbiological work would lead to the "germ theory" of disease. The idea that minuscule infectious cadaveric particles on the hands could account for disease was rejected as irrational by some and offensive by others. As Charles Meigs the respected Philadelphia Obstetrician commented at the time, "Physicians are gentleman... and gentleman's hands are clean". Other noted medical authorities of the day likewise criticized the findings with vehemence and declared them unscientific.

The ensuing controversy with all of its political uproar soon cost Semmelweis his position in Vienna and he was forced to take an unpaid honorary position as head of Obstetrics at a small hospital in Pest, Hungary. There he again initiated his antiseptic regime, subsequently only eight patients would die of childbed fever in his clinic in the next five years. Eventually, he was able to obtain a more respectable position as professor of obstetrics at the University of Pest. Once again maternal mortality declined dramatically. Despite this and despite finally publishing himself at this time his findings he was dismissed by the obstetrical community of Europe, his ideas described by one respected obstetrician as "naive" and the "Koran of puerperal theology".

Over time Semmelweis' railings against the established medical doctrine grew more strident, he became obsessed with puerperal fever, and increasingly depressed at the rejection of his work. His behavior also began to become erratic and inappropriate. It is unclear to what extent his rapid decline was a result of stress from the rejection of his ideas. Some speculate that he was evincing signs of the neurologic sequela of tertiary syphilis, acquired either from a prostitute he was reported to have been frequently seen with or as an occupational hazard, often seen at that time, from his work. Be that as it may, as his condition worsened his friend and former professor, Ferdinand von Hebra, arranged, without Semmelweis' knowledge, to have him involuntarily committed to an insane asylum. When Semmelweis realized, too late, what was occurring he attempted to resist his commitment. In the process he was severely beaten by the hospital guards. In a painfully ironic twist of fate, he died two weeks later when an infection from his wounds seeded his blood leading to overwhelming sepsis, the same condition, from which he protected so many of his patients. Ignaz Semmelweiz was 46 years old.

A physician who spent nearly ten years at the US Food and Drug Administration, Dr. Maher, has authored peer-reviewed articles for the medical literature, authored a chapter on the genomics of rare diseases for a text book of rare disease therapy and writes on his website on neglected questions of medical importance as well as pointing out historical medical fallacies. You may find more of his work at The Skeptic's Health Journal Club

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Is Colloidal Silver A Treatment For Bronchitis?

By Wyatt McKinney

What is Bronchitis?

Bronchitis is defined as an inflammation of the bronchi. Bronchi are airways in the respiratory tract that bring air into the lungs. This inflammation is typically caused by viruses or bacteria, but it may also be caused by inhaled irritants, such as cigarette smoke or harmful chemicals.

Most cases of bronchitis cases involve a viral pathogen. The inflammation is usually the result of the mucus lining of the airways becoming swollen due to irritation. Anyone may contract bronchitis, but people with weak immune systems, such as children and the elderly, are particularly vulnerable.

What are the Symptoms?

Coughing up phlegm or spit, difficulty breathing, and wheezing are all common bronchitis symptoms. Patients typically seek treatment for bronchitis once the coughing becomes uncomfortable or painful. If the inflammation is particularly severe, fatigue, fever, or chest pains may arise. In rare cases, gastrointestinal bronchitis symptoms may arise.

How can you Prevent Bronchitis?

A vaccine for a Haemophilus influenza, which commonly causes bronchitis, was developed in 1985. However, since the vaccine only boosts immunity for six months, it is typically only administered to those most at risk.

Anyone who wants to limit their risk of bronchitis should stop or not start smoking. Even secondhand smoke may lead to bronchitis. Workers who are often exposed to dust or irritating chemicals should wear a dusk mask to prevent inhalation. Everyone who wants to decrease their risk should also limit their exposure to air and traffic pollution.

How is Bronchitis Treated?

There is no medical cure for bronchitis. Typically doctors will treat the symptoms to alleviate the pain and discomfort, and wait from the body to naturally correct the inflammation. Far too often, doctors will prescribe antibiotics. However, for the large majority of cases of bronchitis, this is inadvisable.

Most bronchitis cases are the result of a virus, and antibiotics are only designed to treat bacterial infections. Many doctors are aware that antibiotics are ineffective for bronchitis, but prescribe them anyway because they feel pressured by the patient to treat something besides the symptoms.

A study from 2002 titled “Azithromycin for acute bronchitis” published in the medical journal “The Lancet” referred to this pressure from patients, concluding that “Many patients with acute bronchitis require their physicians to 'do something.' “And that it should not include the “defensive use of ineffective antibiotics."

Immunologists have long warned that over prescription of antibiotics will only lead to stronger and more resistant bacterial strains. Unnecessary prescription of any medicine can be harmful, and patients who take antibiotics may suffer side effects such as vomiting, headache, and rash.

Since the immune system is the best (and in most cases, the only) way to fight the infection that causes bronchitis, patients might benefit from taking supplements that support and boost the immune system.

Many have claimed good results with taking colloidal silver for bronchitis. Colloidal silver can be taken orally or through a nebulizer.

If you would like to take colloidal silver for the treatment of bronchitis, it may be interesting to note that some patients have reported the best results with true colloidal silver versus inferior products that are mostly ionic solutions.

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