Bailey K. Ashford and Robert A. Phillips Research Awards

Last week I ended up spending more time than I would have liked at Walter Reed National Military Medical Center, because on Monday and Wednesday, I was competing for the two research awards at the hospital the Bailey K. Ashford Award and Robert A. Phillips Award. It was the first year that preventive medicine residents from WRAIR were allowed to compete, so I submitted my abstract on poisoning hospitalizations that I did at AFHSC several months ago, and was selected as a finalist for both.

Here's a picture of Bailey K. Ashford. He was an Army physician in the Spanish American War. After the war, he was sent to Puerto Rico to command the medical department troops (which today would a job given to a Medical Service Corps officer, not a doctor, because it's a pretty thankless job and kinda like herding cats. We don't listen to directions well). While he was there, he noticed that the Puerto Ricans were not only shorter than Americans, but that most of them were anemic. This led him to discovering a new species of hookworm and spent a year working on treating around 300,000 Puerto Ricans, reducing the death rate from anemia by 90% on the island. After this, he established the Puerto Rican Institute of Tropical Medicine and Hygiene, which is now part of the University of Puerto Rico School of Medicine. 

And this is Robert A. Phillips. He was a Navy physician and served in the Naval Reserves during WWII. In 1945-46, he was sent to Cairo to study typhus and ended up establishing the US Navy Medical Research Unit #3 (NAMRU-3), which is still there today. His first big assignment as the commanding officer of NAMRU-3 was a cholera outbreak in Egypt. In that outbreak, his research on cholera and treatment made him pretty much the world expert in it until he died in 1976.

In the good old days of the National Capital Region, when the Army had Walter Reed and the Navy had Bethesda, these were two separate competitions (Bailey K. Ashford at Walter Reed and Robert A. Phillips at Navy), and the two had nothing to do with each other. Four years ago, however, we all had to learn how to play well together, and both competitions were open to residents and fellows from either service. The main difference is that Bailey K. Ashford is for graduating residents, and Robert A. Phillips is for any resident. So there was quite a lot of overlap in the people competing for these awards, including me.

I didn't get the Robert A. Phillips award--it went to an Army orthopedic surgery resident who came up with a new system of classifying lumbosacral fractures--and the Bailey K. Ashford won't be announced until residency graduation in June, but I'm not exactly holding my breath. These are clinical research awards, which judges who are clinicians, and these people rarely consider epidemiology to be clinical research. Whatever. I was just happy that I was selected to be a finalist in both, because that meant that: a) someone recognizes the value of epidemiologic research; and/or b) someone thought my research was interesting enough that they wanted to hear me talk about it. And it got me out of clinic for two days, which is always a plus.

Last Day of the TB Course

Today was the last day of the Denver TB Course (in case you couldn't tell from the title of the post). Most of the lectures today were about non-tuberculous Mycobacteria, or NTM. These are bacteria that are related to TB, but a little bit different, and so they cause a little bit different kind of disease. They're also usually more difficult to treat, sometimes requiring medication for years to a lifetime, sometimes requiring surgery. Fortunately, they are also a lot less likely to affect people who are otherwise healthy. Most people who get NTM infections have other diseases, such as HIV, cystic fibrosis, diabetes, cancer, or other diseases that require steroid medication. That isn't to say that otherwise healthy people can't get NTM infections, it's just more rare.

That being said, because TB is becoming so rare in the United States (and chronic diseases are becoming more common), most of the Mycobacteria in the US is actually NTM.

We also talked about multi-drug resistant TB (MDR) and extensively drug resistant TB (XDR), which are becoming increasingly common around the world (remember the report in the news a few years ago of the guy who flew all over the place with TB? He had MDR, and ended up at National Jewish). MDR and XDR are increasing around the world in large part because people don't completely treat their TB infections. It's a long course of a lot of medications--a typical TB infection in the lungs requires two months of taking four drugs, followed by four months of two drugs--and while the WHO calls for all of that to be directly observed therapy (DOT) to make sure that all of the doses are taken, resource-limited countries aren't all that great at always doing it. People who take the medicines for a short time and then stop, or take some medicines but stop others, increase their chances of ending up with a drug-resistant form of TB that is very difficult to treat.

In all, the TB course was pretty valuable and I feel like I learned a lot that will help me in the future. There was some stuff that isn't necessarily relevant for a preventive medicine physician (if I get a person with MDR-TB, I'm not going to be treating him or her; I'm going to be calling my friendly infectious disease physician and handing the case over), but it was still interesting. So you can rest assured that your tax dollars went to a good place (at least this once).

Not quite timely, but still appropriate:

TB Course, Days 2 and 3

I realized this morning that I forgot to write about my day at the TB course yesterday. Oops. So today's entry will serve for both days. First of all, here's a picture of National Jewish Hospital back when it opened as a TB sanitarium in 1899:

Yesterday was a mix of helpful and not helpful information, which mostly means things I will need to know as a preventive medicine physician and things I don't need to know. How to screen people for latent TB is something that I need to know, because that's something that preventive medicine physicians do. Here's the reason why:

 

What this says is that if you have 100 people who are exposed to TB, 70 will be fine and 30 will become infected, which is known as latent TB infection. Since TB is such a slow-growing bacteria, for 27 of those, the infection will always be latent and they will never have active TB. For the remaining 3, half will have disease within two years, and the other half will have disease later in life (okay, bad example, since you can't have half a person, but you get the idea). The point of treating people with latent TB is to reduce their risk of having active disease in their lifetime from roughly 10% to less than 1%.

And this is how you screen someone for latent TB. When you have a person at high risk, such as someone born outside of the US or someone who has been around someone with active TB, you do either a TB skin test, which is also known as a PPD; or a blood test (IGRA, or immunoglobulin release assay). If that comes back positive, you do a chest x-ray to look for active TB. If the chest x-ray is abnormal, you probably end up treating for active TB, but if it's normal, they're said to have latent TB. And again, the reason why we treat people with latent TB is to reduce their risk of progression from 10% in their lifetime to less than 1%.

That was a good deal of yesterday and a bit of today. Today we also did a workshop for TB outbreak investigations, which was interesting, because there's a change I'll be in charge of one of those someday. It was kinda a good feeling that I got during this workshop, because I felt like I had a better handle on the situation than most people in my group, which makes me think that if I have to do that someday, that maybe I won't mess it up too bad.

Here's a parting thought for tonight, from the CDC doctor who was sent to Colorado to close their sanitariums and ended up staying for the rest of his life:

Denver TB Course

As seems to be the trend for this year, I'm again away from DC, this time to Denver for the Denver TB Course at National Jewish Hospital. Here's a picture of the building the course is in:

This is the 49th year of the TB course at National Jewish, which established itself as a TB mecca of knowledge, so to speak, back in the days of sanitariums. What I didn't realize until the History of TB lecture today is that the practice of sanitariums started in Europe, in the Alps, around 1865. In the States, it started in the Adirondacks in 1884 with Trudeau (the great-great-grandfather of the comic strip artist, I believe), a physician in New York, who was diagnosed with TB. At the time, that was pretty much a death sentence, as they didn't yet have antibiotics to treat it. So he left his practice and went up the Adirondacks to relax, and his symptoms improved. They thought it was the elevation. Well, since the Adirondacks are pretty miserable for most of the year, and the Rockies are fairly nice, the practice of traveling to sanitariums moved from upstate New York to Colorado. More people traveled to Colorado for TB treatment than to strike it rich at the gold rush.

After our History of TB lecture, most of the lectures were introductory, covering topics such as transmission, immunology, diagnostics, and chest x-ray findings. Most of it was pretty dull, actually, although I did pick up a few pointers in the x-ray lecture. I'm hoping tomorrow will be more exciting. We'll be discussing some challenging cases that they've seen here at National Jewish, than latent TB infection (which is pretty much all preventive medicine physicians deal with, in terms of TB), and more about treatments and drugs. Should be a good time.

Last Day of Teaching!

Today was the last day of teaching/evaluating the trainers, and all in all, it went pretty well. Like yesterday, they had one real lecture, and then the rest of the time was spent working on an exercise. Today's exercise was pellagra in South Carolina around 1916ish, which is a case that I did last year in my Epi Field Studies class. The case is set up as a mystery illness, referring to it as "the disease" throughout. The reason they did this (and by "they", I mean the CDC, since it is a CDC case) is to get you to think outside the box as far as outbreaks. Most people think of outbreaks as infectious diseases, but pellagra is a dietary deficiency of niacin, one of the B vitamins (B3). I think the goal was to trick people into going down the infectious disease pathway, instead of immediately thinking of dietary deficiencies, which is where most medically-trained people would go at the word "pellagra".

If it were an infectious disease, though, it would be a strange one, because it didn't affect infants under 12 months old, affected children more than adults, women more than men, married women more than single women, older people more than young adults, and people who worked in the factories least of all. The reasons for this are that infants are breastfed or get milk preferentially when the family has it (milk has niacin); children are growing and therefore need more nutrients; women with families are a) getting pregnant and have the dietary requirements of that, b) are breastfeeding, or c) are giving their children/husbands the good food preferentially to themselves; factory workers get lunch at work, provided by the factories; and older adults are no longer working and therefore no longer getting their diets supplemented by their jobs. People who lived in the same houses were more likely to be affected, but that's only because people who live in the same houses usually have similar diets.

So we went through this case, and there were some minor things that the trainers didn't do perfectly (such as saying that work had no affect on the disease, because people with jobs had lower rates; they should have said that work was a protective factor) and some things that the students had questions about afterwards (mostly relating to cultural questions and things they didn't understand about early 20th century South Carolina, not that I can blame them... I don't know much about early 20th century Ukraine), but overall, it went really well, even better than yesterday's exercise.

After the day of teaching (which ended a bit early), we headed back to the hotel and then went down by the Opera House for dinner. Here's a picture of the Opera House:

And again at night:

We ended up eating at a Belgian place (called Belgian Bar Restaurant), which had really good, although a bit more spendy than what we had been paying (and by "more spendy", I mean still significantly less than per diem), and then stopped at a chocolate place for dessert. We were going to get hot chocolates, but were both too full from dinner. Maybe tomorrow.

Legionella Outbreak Exercise

Today was another day of more of the same of what I did yesterday, sitting in the back of the room with the translators as I evaluated the quality of the teaching being done by the Ukrainian trainers. It was a little more challenging than yesterday, though; for one, I was doing most of the evaluating, instead of Dr. Smoak, and two, the material is getting much more challenging.

The most time-consuming part of the day was one outbreak exercise, a look at a Legionella outbreak in Louisiana from 1989. The exercise starts by stating that a hospital, noticing an increase in pneumonia cases way above the normal, calls the state health department for help. Unfortunately, the exercise then gets into a long and detailed description of what Legionella pneumonia is, and then goes back to give a table of all the pneumonia cases by month in this one hospital for the last four years. So that confused both the students and the trainer, who assumed that the table was all Legionella cases, not pneumonias of various types. They spent far too much time analyzing the table, trying to get seasonality trends and whatnot for Legionella based on it. I pointed out the distinction to the trainer, who, after the break, set them straight and explained that the purpose of the table was to show that it was the sudden jump in pneumonia cases that got the hospital's attention, and at this point, they didn't realize it was Legionella.

The next hang-up in the case is a perfect example of the difficulties of working with a translator (especially when that translator is the old guy who doesn't translate very well). The exercise notes that there are several water towers, cooling tanks, and paper pulp processing plants in the city, and asks if we should check each one for Legionella. The students discussed this, and to me, it sounded like they wanted to. The trainer also seemed to be going back and forth, from what I was hearing. He asked at the break what we would do and why; I explained that it would be premature to sample everything, because Legionella lives in all sorts of water tanks, and that the purpose of the case-control study that the exercise is about is to find what the cases have in common, and then you can focus your testing, instead of testing every water tower, air conditioner, etc in the entire city. Well, the translator mistranslated that explanation, and after the break, the trainer said that we should test everything. So I very quickly jumped in and redirected and reminded them that this is why we were doing a study. This is also a difference between Soviet epidemiology and Western epidemiology; whereas we are very analytical (doing studies, performing statistics, etc), they tend to be more descriptive and immediately reactive. There were new paper pulp processing plants in the town and new cases of pneumonia; therefore, the paper pulp processing plants are the culprit and we should test to confirm. Fact is, because Legionella is everywhere, they probably would have found it, and completely missed the true source of the outbreak, and people would have kept getting sick.

It turned out (and this was a real case), it wasn't the pulp plants or the water towers; it was the produce misting devices at the grocery stores. I didn't really think about it until reading through the case, but I remember the mist at the grocery stores when I was younger, and then places just stopped having them. Turned out, they stopped having them because this town in Louisiana noticed that people were dying of Legionella because of them. What would happen was the Legionella bacteria would grow in the water tanks, and then be released with the water when it would spray the produce. The people nearby would breath it in, and if they were unfortunate, get Legionella pneumonia (and if really unfortunate, die). The worst part was, the mist did nothing to keep produce fresh longer; it was just to make the customers think it was more fresh and to attract them to the fruits and vegetables. 

Anyway, that whole exercise took about three hours today, and I don't know how much the students really got of it (hopefully, if nothing else, that this is why we do studies instead of go with our first instincts). After the case was over, Dr. Smoak and I took the trainers out to dinner. We went to a restaurant (or, as it appears in Ukrainian, pectopah) called Praga (and I can't write what that looks like in Ukrainian, because my keyboard doesn't have those symbols). It was quite scenic; here was the view from our table:

 

After dinner, I ordered hot chocolate for dessert. In Eastern Europe/former USSR, hot chocolate is pretty much a bar of chocolate, melted in a cup. It was delicious.

Tomorrow is the last day of teaching, and like today, I'll be the one doing most of the evaluating (we have another long and challenging case). And then Friday the students graduate from Module 3 and I finish buying souvenirs (probably chocolate), and then Saturday, on home.

Day Two

Today was the second day of the epidemiology course, which didn't require any teaching from me (yay!). Instead, my job was to sit in the back of the room and either: a) mess around on my iPad while Dr. Smoak evaluated the Ukrainian trainers; or b) have the translator sitting next to me talking pretty much right in my ear to translate what the trainers were saying so I could evaluate them. Needless to say, option a was more fun.

We have two different translators for this course, a really nice and fairly young Ukrainian woman, and a fat, old Ukrainian man who smells like a mixture of vodka, cigarettes, and the cheap mint breath spray he uses to cover up the first two smells. Needless to say, the woman is the ideal, but aside from her more pleasant aesthetic features, her translations are also much easier to understand. The man messes up numbers all the time (and numbers are kinda important when you're talking about disease surveillance and epidemiology/biostatistics) and tends to get lazy when he thinks it doesn't matter.

Translators aside, the students seemed to be doing fairly well with understanding the material, which, one can conclude, means that the trainers are doing fairly well. We've identified a few minor issues over the last two days (many of which might be semantics), which isn't bad at all. Hopefully this continues through the week.

First Day of Teaching

Today was the first day of actual work in Ukraine (I know... Sad). So after getting up, working out, and having a delicious breakfast (provided by the hotel), we got in an embassy car and made our way do another part of Kiev to start the class.  Most of the students were coming in from overnight trains, so things got off to a bit of a delayed start (around 10), but then it went well from there.

After all the introductions and whatnot, the Ukrainian trainers got to work. For most of this week, we're here to evaluate the Ukrainian trainers as they teach the material. This is the third module of epidemiology teaching (out of four) that the students (public health officials/epidemiologists throughout Ukraine) get. When the program first started, everyone was trained by Americans at all levels. Then they began training Ukrainians to do the first two modules, and now no Americans teach those. This will be the first group of Ukrainian trainers for the last four modules. No other country has their own trainers for modules three and four. 

I did get to try my hand at teaching through a translator near the end of the day, though. I gave the first lecture on cohort studies, and I think it went pretty well. Here's me teaching:

 

 

And then waiting for the translation:

It was 26 slides, but took about an hour and a half to get through, in part because I had to stop every sentence for the translator, and in part because the students had never had any material on cohort studies before. I think they did pretty well, though. Time will tell... They have a post-test on Friday.

Still Exploring Kiev

Today was more exploration of Kiev (and more shopping for souvenirs). We went to Maidan Nezalezhnosti, or Independence Square, which was where Ukraine celebrated independence from the Soviet Union in 1991, and also where the Orange Revolution was in 2004 (to protest election corruption). Today, it's pretty much just a central square of Kiev. They're also gearing up for Euro2012 (soccer), which explains this picture:

 

 We also passed by a theater with some interesting decorations to their buttresses:

Here's another picture from St. Michael's Gold-Domed Cathedral, which I also had pictures of yesterday. The church in the foreground is an old stone church from elsewhere in Ukraine that was moved to the cathedral grounds (I don't know why).

I also wandered up to Volodymyrs'ka Hill, which is a park close to Independence Hall. It's so named for the statue of St. Volodymyrs of Kiev, who was the guy who baptized all of Kiev, back in 988(ish). I think his statue is in the middle under the arch, but I'm not sure.

Here's another shot from Independence Square:

And, finally, some interesting characters that we met along the way:

Tomorrow begins the actual work of this trip. I'm going to be evaluating future Ukrainian trainers of epidemiology, and giving a lecture of my own. Should be interesting.

Arrival in Kiev

For those of you who didn't know I was going to be spending a week in Ukraine teaching epidemiology... Surprise! I'm in Ukraine for a week to teach epidemiology. After far too many hours of travel by plane, train, and automobile (okay, just plane and automobile, no trains involved on this trip...so far), I checked into my hotel in Kiev. And what a lovely hotel room it is.

 My preceptor for this trip, Dr. Smoak, has been here for a week already doing the first part of the training (two weeks total: week one is to teach them epidemiology, week two is to evaluate them teaching the same lectures back. That's the part I'll be doing), so after I unpacked and cleaned up somewhat, she took me out to see the part of the city where we are and do some souvenir shopping. Here is one of the churches (I don't remember the name, but I'm going to find out):

This church also had a memorial for the 1932-33 famine in Ukraine, pictured below:

To try to explain this famine briefly, without getting into complicated Soviet politics and history, in the Soviet system, there were common fields that all peasants were supposed to work, as well as small plots that individual/families maintained. In 1932, there was a pretty severe drought, and they discovered that people didn't really do anything in the common fields when there was work to be done on their own fields. So grain production was really, really far down. The Soviet solution to this was to take from the Ukrainian peasants who managed to produce anything, because they blamed the failure of the common fields on Ukrainian nationalism. In two years, millions of Ukrainian peasants starved to death due to the Soviet distribution policies, which was later determined to be a form of genocide. If you look at censuses that were done around this time (a few years before and a few years after), the Ukrainian region was the only part of the USSR that had a decrease in population. So the Soviets were selectively starving Ukrainian. They were bad people. But we knew that.

On a happier note, here's another church. Dr. Smoak said that this one had specific cultural/historical significance, but she couldn't remember what it was.
 

And, finally, a picture of the statue of the architect of Kiev.

That was my day/last couple of days. A bit hectic and definitely exhausting, which is why I'm about to go to bed. Tomorrow, possibly more walking around/souvenir shopping, and then Monday we have to go to work.