What a patient with Ebola experiences

sextonA patient who survives Ebola suffers through some nasty symptoms, and then his or her body regroups to muster a fight against the virus.

“One of the big problems with this disease is it impairs adaptive immunity. You don’t develop an antibody response initially, so you’re not killing off the virus appropriately,”

James Sexton, MD, an assistant professor of medicine in pulmonary and critical care at Upstate University Hospital, told medical staff Tuesday in a lecture about the disease that’s on everybody’s mind.

Infectious disease precautions are part of standard training for doctors, nurses and other hospital staff. They have been practicing how to care for a patient with Ebola since before Upstate was designated one of eight hospitals in New York State that would handle Ebola patients.

People who arrive at Upstate are asked whether they have traveled to West Africa or had contact with anyone who has been diagnosed Ebola. “The priority here is identification and safe handling of that patient and protection of our staff,” explains Christopher Dunham, Upstate’s director of emergency management. Anyone suspected of having Ebola would be placed in an isolation room. Then as their treatment began, a doctor from Upstate would confer with Onondaga County and state health officials, and the Centers for Disease Control and Prevention.

Part of the preparedness training at an academic medical center such as Upstate includes educating staff in the science of the disease, which is what Sexton’s lecture accomplished.

He said most people develop symptoms five or six days after they are infected, although the incubation period for Ebola is considered 21 days. Some people have developed symptoms beyond those 21 days.

An infection with this outbreak of Ebola has typically begun with flu-like symptoms of fatigue and fever. Initially, the virus affects white blood cells called macrophages and the dendritic cells, which are part of the immune system.

The diarrhea that develops can be severe, with patients losing up to 10 liters per day. “Obviously you’re going to have all sorts of problems from fluid and electrolyte losses if you’re putting out that much diarrhea,” Sexton said.

Ebola also causes vomiting, loss of appetite, headache, abdominal pain and muscle aches. Weakness comes from dehydration.

Patients have reported nonproductive coughs and sore throats with the sensation of a lump in the throat. Some have developed eye infections, and some have seen their mouths become dark red in color.

A rash may develop that later peels.

A patient who is pregnant when she is infected is likely to miscarry.

Some patients struggle with a low platelet count, which impacts their blood’s ability to coagulate. Bleeding, however, is not a common symptom.

People are not infectious until they have symptoms, and Ebola has no respiratory spread. “You can only catch it if infected fluids contact mucous membranes or somehow get direct contact with blood, through breaks in the skin or needle sticks,” Sexton said.

He said the virus damages the tissue of the liver, adrenal glands and spleen. Even though the body at first does not create antigens, it does mount an inflammatory response. Cells that are damaged release chemicals that cause swelling, which helps insulate the tissues from the virus.

“When you do develop an antigen response is really when you start to get better, if you’re going to get better,” Sexton said. “People who never develop an antigen response die.”

Improvement or death usually occurs between day 6 and day 16. People who die from Ebola suffer multiple organ failure and septic shock, a full body infection that leads to a dangerously low blood pressure.

People who survive Ebola face a lengthy convalescence. Weakness, muscle aches and fatigue are liable to linger, and weight regain can be difficult. Sexton said there may be hair loss and extensive sloughing of skin. Also, the virus may remain present in semen and breast milk for weeks or months.

People who survive Ebola likely develop an immunity to that strain of Ebola, Sexton said. “No one, as far as I know, has been exposed to the disease a second time, but because you now have an antibody response, you may not be able to get the disease again.

Sexton said experts believe “the antibody response is key. Once you develop that, you get over the disease,” he said. “The big problem with the disease is you don’t develop that for so long — until it’s gotten so bad that it’s caused all these other problems.”

Christopher Dunham explains how the hospital has prepared for Ebola

Timothy Endy, MD, tells the science of Ebola

Facts about Ebola

Almost 1.07 million people in Africa do NOT have Ebola.

Ebola belongs to the same order of viruses — called the Mononegavirales — as measles, mumps, rabies and Marburg, a hemorrhagic fever virus.

There are five strains of Ebola. The one grabbing headlines lately is called Zaire, and it is responsible for two current outbreaks — the large one affecting Guinea, Liberia and Sierra Leone as well as a smaller outbreak in an isolated village in the Congo.

The mortality rate for the large outbreak, through Oct. 26, is 49 percent. Of 10,207 people infected, 4,971 have died.

The virus is not a respiratory virus. It enters the body through the mucus membranes or a break in the skin. Cases of transmission have also been reported through needle sharing and through the ingestion of meat from bats, monkeys or primates that carried the disease.

The blood, feces and vomit of someone with Ebola are most infectious. Urine, semen and breast milk are less so. Saliva and tears may be infectious. Sweat is probably not.

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Brain expertise featured in Physicians Practice publication

PhysiciansPractice1114The stroke care and brain expertise available at Upstate is showcased in the November issue of Physicians Practice magazine, distributed to doctors throughout Central New York. Also included is an article about new breast reconstruction options, the importance of occupational history, the connection between health care workers and liver cancer, and more.

Browse all of the Upstate content.

 

 

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Blood in urine is never normal

Image from iStockPhoto.

Image from iStockPhoto.

Blood in the urine does not necessarily indicate bladder cancer, but it does warrant a visit to a urologist, says Srinivas Vourganti, MD, an assistant professor of urology at Upstate.

Bladder cancer occurs mostly in older people, and smokers are three times as likely to be diagnosed as nonsmokers. Also, men are three or four times more likely than women to get bladder cancer during their lifetime. The usual first symptom: blood in the urine.

Patients are evaluated through a combination of X-rays, urine and blood tests and a procedure called cystoscopy that allows a doctor to visualize the inner lining of the bladder. Any abnormal growths are removed and examined to identify cell type, aggressiveness and how deep the tumor was attached.

About half of bladder cancers are confined to the smooth mucosal lining of the bladder, but the cancers can spread into the deeper layers, or beyond the bladder. “Each depth of invasion is associated with worse outcomes,” Vourganti explains.

Treatment varies. The more advanced diseases may require radiation therapy and/or medications, or the removal of the bladder. Tumors confined to the lining can be removed, but they are like weeds with a tendency to grow back. Vourganti says that is why bladder cancer has the largest economic impact among cancers. “There is an intensive surveillance that has to happen to prevent its progression,” he says.

Cigarette smoking or exposure to industrial chemicals called aromatic amines contributes to many bladder cancers. (Aromatic amines are sometimes used in the dye industry; workers at high-risk for exposure include makers of rubber, leather, textiles or paint products, painters, machinists, printers, hairdressers and diesel truck drivers, according to the American Cancer Society.)

With every heartbeat, our kidneys make small amounts of urine, which is stored in our bladder until we void. Since many toxins in our body are filtered out through the urine – including the carcinogens from cigarettes and aromatic amines — the bladder is exposed to these toxins.

That makes smokers who work with cancer-causing chemicals at especially high risk of developing bladder cancer.

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Are you at risk for on-the-job cancers?

Asbestos was strong, durable and heat resistant, “so it was used in lots of products,” says mesothelioma lawyer Joseph Belluck. “Every year we learn about more and more products that asbestos was used in.”

Belluck was among the speakers at the 10th annual Upstate Cancer Symposium, which focused on occupational cancers. He pointed out that asbestos is still used industrially today, “and there are still many people being exposed to asbestos every day in this country.”

Jerrold Abraham, MD, provided this image from a paper he co-authored in 2002 in the American Journal of Respiratory and Critical Care Medicine, from a case about someone who died from asbestosis 50 years after a brief exposure in a Vermiculite expansion plant.

Jerrold Abraham, MD, provided this image from a paper he co-authored in 2002 in the American Journal of Respiratory and Critical Care Medicine, from a case about someone who died from asbestosis 50 years after a brief exposure in a Vermiculite expansion plant.

Lung cancer, bladder cancer and the aggressive cancer of the lining of the lungs and abdomen called mesothelioma account for the majority of work-related cancers in America. Belluck told symposium attendees that patients diagnosed with mesothelioma in the United States have the cancer because of asbestos.

Because mesothelioma has a lengthy latency period, people may not develop symptoms for 10 to 40 or more years after exposure. An estimated 27.5 million people were exposed to asbestos from 1940 to 1979. Early symptoms can be vague: pain in the lower back or side of the chest, shortness of breath, cough, fever, excessive sweating, fatigue, weight loss, trouble swallowing and swelling of the abdomen, face or arms.

Some 3,000 people from a variety of occupations are diagnosed with mesothelioma each year. Among them are shipworkers, construction workers and people who worked in steel mills and factories, but also school teachers, carpenters and electricians.

Michael Lax, MD, medical director of Upstate’s Occupational Health Clinical Center, says that assessing a person’s exposure to cancer-causing chemicals including asbestos over a lifetime is tricky to do with accuracy. He says at least 24,000 to 60,000 deaths per year are thought to be attributable to occupational carcinogens.

Listen to an interview on this subject

“The estimates we have should be considered under-estimates,” Lax says, because only 2 percent of chemicals are tested for carcinogenity before they are put into use. He says that makes American workers unwitting participants in a giant experiment to determine which workplace chemicals may lead to disease. While other organizations recognize more than 110 substances as carcinogenic, the federal Occupational Safety and Health Administration regulates only 27 as cancer-causing.

Lax and Belluck say it’s important for doctors to recognize if a cancer is work-related so that patients can seek treatments that may be effective and compensation to pay future medical bills. Also, such documentation can help researchers trace cancer causes, and possibly lead to safer workplaces.

The first asbestos-related death was documented in 1906, Belluck says, adding that today’s laws regarding workplace safety make companies responsible not just for what they knew, but for what they should have known. The link between asbestos and mesothelioma has been clear since the 1960s, and the link between asbestos and lung cancer since the 1930s, says pathology professor Jerrold Abraham, MD, another speaker at the symposium that attracted cancer specialists and medical students.

Patients may be aware of asbestos exposure, and that should make a doctor aware of the risk for developing mesothelioma, which is diagnosed with imaging tests such as X-rays and computerized tomography, and biopsies. Abraham emphasized that occupational exposures may be evident in patients’ biopsy tissues, but may go unnoticed by inexperienced pathologists.

Hopefully soon, a blood test will be able to aid in diagnosis.

Upstate Cancer Center Medical Director Leslie Kohman, MD introduced a mesothelioma expert at the symposium by saying, “Imaging and history are important, but they will eventually be eclipsed by what we can learn from blood biomarkers.”

Harvey Pass, MD, chief of thoracic oncology at New York University Langone Medical Center, spoke of his dream to be able to screen people for asbestos-related diseases such as mesothelioma before they develop symptoms, or to determine which genes make one susceptible to the disease.

“The earliest we will actually have a validated biomarker is probably within the next four or five years,” Pass told the symposium group.

Already, a molecule has been identified that promotes the growth of mesothelioma. A blood test can tell the difference between someone who was exposed to asbestos and someone with mesothelioma. And, 25 percent of patients with the disease have been found to have a particular genetic mutation.

So, progress is being made.

Listen to an interview on this subject

27 cancer-causing chemicals

The Occupational Safety and Health Administration regulates these substances as cancer-causing:

  • asbestos
  • 4-Nitrobiphenyl
  • alpha-Naphthylamine
  • Methyl chloromethyl ether
  • 3,3′-Dichlorobenzidine (and its salts)
  • bis-Chloromethyl ether
  • beta-Naphthylamine
  • Benzidine
  • 4-Aminodiphenyl
  • Ethyleneimine
  • beta-Propiolactone
  • 2-Acetylaminofluorene
  • 4-Dimethylaminoazobenzene
  • N-Nitrosodimethylamine
  • Vinyl chloride
  • Inorganic arsenic
  • Hexavalent chromium
  • Cadmium
  • Benzene
  • Coke oven emissions
  • 1,2-dibromo-3-chloropropane
  • Acrylonitrile
  • Ethylene oxide
  • Formaldehyde
  • Methylenedianiline
  • 1,3-Butadiene
  • Methylene chloride

Silica is one example of a substance that is not on the list, despite the World Health Organization and the Centers for Disease Control and Prevention saying it can cause cancer.

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How to avoid constipation during cancer treatment

Since everyone is different, the side effects to cancer treatment vary from person to person. One common problem is constipation. Registered dietitian nutritionist Maria Erdman provides these possible solutions:

* Choose foods that are high in fiber for your meals and snacks. Shoot for 20 to 35 grams of fiber each day. Some suggestions from the Mayo Clinic:

FRUITS

1 cup raspberries = 8 grams fiber

1 medium pear, with skin = 5.5 grams fiber

1 medium apple, with skin = 4.4 grams fiber

1 medium banana or orange = 3.1 grams fiber

1 cup strawberry halves = 3 grams fiber

GRAINS, CEREAL & PASTA

1 cup whole wheat cooked spaghetti = 6.3 grams fiber

1 cup pearled barley, cooked = 6 grams fiber

¾ cup bran flakes = 5.3 grams fiber

1 medium oat bran muffin = 5.2 grams fiber

1 cup instant cooked oatmeal = 4 grams fiber

LEGUMES, NUTS & SEEDS

1 cup split peas, cooked = 16.3 grams fiber

1 cup lentils, cooked = 15.6 grams fiber

1 cup black beans, cooked = 15 grams fiber

1 cup lima beans, cooked = 13.2 grams fiber

1 cup baked beans, vegetarian, canned, cooked = 10.4 grams fiber

VEGETABLES

1 medium artichoke, cooked = 10.3 grams fiber

1 cup green peas, cooked = 8.8 grams fiber

1 cup broccoli, boiled = 5.1 grams fiber

1 cup turnip greens, boiled = 5 grams fiber

1 cup Brussels sprouts, cooked = 4.1 grams fiber

* Introduce fiber into your diet slowly, with a few additional grams every couple days. Otherwise, it may cause stomach upset.

* Keep hydrated with plenty of liquids, and if you are increasing your fiber intake, increase your fluid intake, too.

* Stay active with exercise, as you are able.

* Eat at roughly the same times each day.

* Eat breakfast when you start your day, and include both high-fiber foods and coffee, hot tea or hot water with lemon. Hot beverages may act as stimulants.

 

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Breast cancer research at Upstate: Which drug will work best in each patient?

Advances in the understanding, diagnosis and treatment of breast cancer begin in laboratories. Here’s a peek into one lab at Upstate that received grants this year from the Carol M. Baldwin Breast Cancer Research Fund:

005371Which drug will work best in each patient?

A family of molecules known as the Wave Complex interact within our cells. Which molecular family members are present at any given time in the life of a cell determines how that cell will behave: how it gets nutrition, whether and how it moves, whether it remains stationery.

This complex appears to play a major role in the invasive types of breast cancer, says Leszek Kotula, PhD, associate professor of urology and biochemistry and molecular biology. Working on the theory that the Wave Complex could be a target for therapy are Kotula and two colleagues, Steve Landas, MD, professor of pathology and urology, and Mira Krendel, PhD, assistant professor of cell and developmental biology.

When they increase some specific molecules in the complex, the cancer spreads, Kotula says. He adds that by decreasing certain molecules, “we may actually stop metastasis, or greatly affect it.”

The next step will be to test the effects of existing cancer drugs on these molecules. Landas, a diagnostic pathologist for 35 years, sees the potential. “Wouldn’t it be a wonderful thing if we find ourselves in a situation where we can look at certain members of this family of molecules and know with a high degree of certainty which drugs will work and which will not?”

Hear an interview with Kotula and Landas about this project

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Options for women to rebuild breasts after cancer are more plentiful

Prashant Upadhyaya, MD, provides many breast reconstruction options.

Prashant Upadhyaya, MD, provides many breast reconstruction options.

A woman who faces mastectomy also has to consider whether and how to reconstruct the breast that will be removed, and her options have improved in recent years.

“Immediate reconstruction, in which the reconstruction is done when the breast is removed, is the gold standard now, and it is done in most of the patients who are reconstructed,” says plastic surgeon Prashant Upadhyaya, MD, an assistant professor of surgery at Upstate. He says no longer is it common for a woman undergoing mastectomy to wake up from surgery with a flat chest.

Up to 90 percent of breast reconstructions are “immediate,” but some women have to defer reconstructive surgery for medical reasons, and some want to complete cancer treatment before considering reconstruction.

factorstoconsiderBreast reconstruction can be done using implants, or it can be “autologous,” meaning the patient’s own tissue is used to create a new breast. Either way, most health insurers are required to pay for reconstruction of both breasts after mastectomy.

An autologous reconstruction requires an extensive surgery in which tissue is either transplanted from the abdomen to the chest, or moved from the patient’s back to the chest. This appeals to patients who do not want implants containing silicone or saline in their bodies, but not every woman is a candidate for autologous reconstruction, Upadhyaya says.

A woman who opts for implants may also be able to have a surgery that leaves her nipple intact. Newer techniques involve an incision that is made away from the nipple. “It’s actually very well hidden below the breast,” Upadhyaya says. The implants are often inserted through the same incision, and “the patient wakes up with breasts completely intact.”

Although sensation won’t be the same, the surgeon says after a woman recovers from the operation, her breast may appear much as it did before.

He favors silicone gel implants. “Saline implants do not have the natural feel or the look of silicone gel implants. I offer both to patients. But I think the longevity of the results is better, and the feel of the breast is better with silicone implants.”

Implants carry the risk of infection. Upadhyaya says from 5 to 10 percent of patients with implants will face infection, which means having to remove the implants and then, months later, undergoing another reconstruction.

So which surgery provides the best outcome?

The surgeon says the answer has to be based on each individual patient’s expectations – and the realization that they may not be happy with any outcome during the post-operative period. Healing and recovery is liable to take months.

Hear an interview with Upadhyaya about breast reconstruction options

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Bicycle will blend smoothies in cafeteria today

Stop into the cafeteria at Upstate University Hospital’s downtown campus from 11 a.m. to 1:30 p.m. today to sample smoothies blended from fresh fruits and vegetables. Morrison Food Services is hosting a smoothie bike, designed to blend smoothies as a rider pedals.

Dietitians and a chef will be on hand to answer nutrition questions and distribute smoothie recipes. Fresh fruits and vegetables will also be available for sale.

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Breast cancer research at Upstate: What will stop the spread of breast cancer?

Advances in the understanding, diagnosis and treatment of breast cancer begin in laboratories. Here’s a peek into one of the labs at Upstate that received grants this year from the Carol M. Baldwin Breast Cancer Research Fund:

005371What will stop the spread of breast cancer?

The protein, paxillin plays an important role in cell movement. What scientists are trying to determine is exactly how paxillin affects the movement of cancer cells away from a primary tumor, into the blood stream and on to colonize distant organs. It’s important to know because “If we can develop ways in which we can limit paxillin’s function, we may be able to block the process of metastasis,” says Christopher Turner, PhD, professor of cell and developmental biology.

Many of the drugs used to fight breast cancer tumors target microtubules, the proteins that makes up the cytoskeleton that helps cells maintain their shape and internal organization. These drugs create toxic side effects for patients.

“We found that the level of expression of paxillin in tumor cells may actually influence the microtubule cytoskeleton and, therefore, may influence how those drugs actually work in individual patients,” Turner says.

Nicholas Deakin, PhD, research assistant professor of cell and developmental biology, points out that the deaths of 95 percent of the 40,000 American women who die from breast cancer each year are linked to metastasis. “It’s not the tumor in the breast that really is the problem. It’s the ability of the cells to move away from there,” he explains. “If we can detect the tumors early, and if we can then treat them with a drug or know what drug to go with to stop their spread, then that’s going to greatly influence the survival of these patients.”

Hear an interview with Turner and Deakin about their work

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How one workplace supported a co-worker with cancer

Stacy tTo know the real value of a pink cotton t-shirt, you would have had to see the tears streaming down Stacy Wilson’s face.

It was soon after her diagnosis with breast cancer in 2013. She returned to work from a doctor’s appointment. When she walked in, 27 of her coworkers wore bright pink t-shirts with a coupon printed on front.

“This coupon is worth the support of one friend in your fight against breast cancer. Expiration date: Never,” the shirts said.

Wilson was blown away.

She works as an application coordinator in information management technology at Upstate. She’s mother to seven children ranging in age from 11 to 19.

Her co-workers raised about $200 by selling the t-shirts. They also contributed a variety of comfort foods for her family while she was going through treatment.

Wilson finished her treatment in July and has a good prognosis. And she remains ever grateful for the support shown by her coworkers. “It was a huge deal, what they did for me.”

Should you share your diagnosis at work? A psychiatrist gives her advice.

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