Toxic meds only weapon so far against fungal meningitis

NASHVILLE -- When moldy medicine is injected into people's spinal columns, spawning incredibly rare forms of fungal meningitis, doctors have few treatment options and don't know how to keep people from getting sick.

The toll from a nationwide outbreak of fungal meningitis continued to rise Thursday, with 170 cases reported, including 14 deaths, according to the U.S. Centers for Disease Control and Prevention.
The CDC also warned that people who got injections of the recalled lots of steroid medicine, methylprednisolone acetate, in their knees and other joints could develop septic arthritis.

At the epicenter of the outbreak, infectious disease specialist Dr. Robert Latham is doing what he can for the 25 patients with fungal meningitis at Saint Thomas Hospital in Nashville.

His options are limited.

The two antifungal medicines in his arsenal -- voriconazole and amphotericin B -- have such vicious side effects that one carries the nickname "ampho-terrible." The drugs fight the fungus but can damage the liver and kidneys. They shouldn't be given, the CDC says, unless a patient's spinal fluid is clouded by infection.
Patients ill enough to receive the drugs can expect to be tethered to an intravenous drip for months.

Medical research provides little guidance for doctors and scant case history to predict the outcome.

"I don't think anybody in the country or the world, except for some very rare exceptions, has seen anything like this -- certainly not at the volume we're seeing now," Latham said.

But the drugs are showing results, said Latham.

"I can tell you with the people we've been treating the longest, we're seeing improvement in their spinal fluid," he said.

No preventive medicine

Dozens more people sick with worry come to the hospital wondering if the soreness in their necks is from tension or a first symptom of fungal meningitis -- something they may have contracted through tainted epidural spinal injections at the Saint Thomas Outpatient Neurosurgery Center on the hospital's ninth floor.

Desperate to keep from getting ill, the patients from there and two other Tennessee pain clinics ask for preventive medicine.

"Do they not have something if this was to occur?" said Lourdes Gonzalez, who got her injections of the potentially contaminated steroid at the Specialty Surgery Center in Crossville.

But health officials say they know of nothing that can protect those exposed to the recalled drugs.

For people who show symptoms of the disease, a doctor will perform a spinal tap so the fluid can be tested for fungi linked to the outbreak. If the test turns out negative, the patient is sent home -- but without a clear bill of health. The pathogens can hide inside the spinal canal and not show up initially.

The CDC currently does not recommend prescribing the antifungals as a preventive measure. Some of the nation's top infectious disease experts have talked about the pros and cons of such an action, but they can only guess whether a pre-emptive strike would work.

"We would be going to Mars, in effect," said Dr. William Schaffner, a Vanderbilt professor who is president of the National Foundation for Infectious Disease.

Using the medicine in such a way could be potentially hazardous to patients, who may have gotten injections from a fungus-free vial, Shaffner said. And he said there's no proof that the treatment would keep people from getting sick.

Small chance of illness

Most people exposed to the possibly tainted drugs will not get fungal meningitis, health officials say -- although some may have better chances than others, depending on which lot of recalled medicine was used for their injections.

Three lots of methylprednisolone acetate were recalled, but one has shown a higher "attack rate" than the other two, said Dr. David Reagan, chief medical officer for the Tennessee Department of Health.

Even for those receiving shots from that lot of medicine, the chance of illness is relatively small, Reagan said. "Currently, it changes, but it is a bit less than 5 percent of the people that have been exposed.
"Some lots have substantially less percentage than that."

Symptoms of meningitis include stiff neck, worsening headache or fever.

Infection of an arthritic joint, such as a knee, may be occurring if someone who got an injection suffers new or worsening pain with swelling, redness, and warmth at the injection site, according to the CDC.

Knowledge sharing

 Scientists and doctors are learning more about the outbreak day-by-day. At first, only one type of fungus, Aspergillus, was thought to have contaminated the steroid medicine. Over the weekend, the CDC said it had found a second fungus. On Tuesday, the Tennessee Department of Health announced that the majority of the cases in this state were actually from Exserohilum, the second type of fungus.

Tennessee Health Commissioner Dr. John Dreyzehner characterized this form of fungal meningitis as "an exceptionally rare disease."

Cases so far indicate that the antifungal medicines help people who are diagnosed and treated early, Dreyzehner said. "There is a balance here, though, because they are potentially very toxic medications."
The CDC is also advising doctors to prescribe antibacterials because they are not yet sure what contaminants may have been in the recalled medicine.

Latham and other doctors are looking to the CDC for better guidance on the use of the antifungals, particularly among older people with reduced kidney function, Dreyzehner said.

Experts are sharing their knowledge in conference calls. And the CDC has a team of scientists gathering outcome data, researching the scant accounts in medical literature about these rare illnesses and comparing notes on the best ways to use the medicine.

Said Schaffner: "Let's remember that we're in new territory."

Depression Screening Day offers help online, in person

Often dismissed as a case of "the blues," depression can cause serious harm if left undiagnosed or untreated, says Douglas Jacobs, associate clinical professor of psychiatry at Harvard Medical School and founder of Screening For Mental Health, Inc.

To counter that, more than 1,000 sites across the USA, including colleges, community organizations, and military installations, will offer free anonymous screening tests for depression and other mental health issues today through National Depression Screening Day. The assessment, also available online at www.HelpYourselfHelpOthers.org, will evaluate individuals on 13 multiple-choice questions about everything from appetite and sleeping patterns to changes in mood and behavior.

It's sponsored by Screening for Mental Health, Inc. and the free in-person services will continue at some facilities through October, so check the list of participating groups online, says Katherine Cruise, spokesperson. The online screening tool will be available year-round.

"When we started National Depression Screening Day in 1991, about one-third of people who suffered from depression received treatment ... now about 50% of those who suffer from depression will get treatment each year. That still leaves a significant number who do not receive treatment," says Jacobs. "The bottom line is, the earlier the intervention, the better likelihood for a positive outcome."

It's important that people take the screening either online or in person, or refer their friends and family who may be at risk, Jacobs says. The screenings provide a score, rather than a diagnosis, and will evaluate whether the results are consistent with an individual suffering from a mental health issue. Mental health clinicians will be on hand to provide information and to direct individuals to mental health providers as needed.

Although a significant number of people suffering from depression do not get treatment, the results of a recent poll show most Americans wouldn't hesitate to seek help for mental health issues. A telephone survey of 1,021 American adults found that nearly 3 in 4 individuals said they would likely speak to a health care professional if they believed they exhibited signs of depression.

Nearly two-thirds of those surveyed said they believe depression can be successfully treated often and more than half said they know personally know someone who has undergone treatment for depression.

The survey provides hope that people will consider seeking help for mental health issues, but there's a difference between considering it and actually going to see your health care provider says Carlos Zarate, chief, Section of Neurobiology and Treatment of Mood Disorders at the National Institute of Mental Health.
"It's fair to say that more people recognize treatment and more people are considering it ... but the reality is that many are still not diagnosed with depression and the problem is that very few actually go and receive treatment," Zarate says.

Celebrities and public figures stepping forward in recent years and speaking out about depression and other disorders has helped reduce the stigma associated with seeking help for mental health issues, Zarate says. However, family and friends can play a pivotal role in encouraging their loved ones seek help.

"Oftentimes the person who is ill has a hard time getting motivated and the family and friends can help by going in with them. Sometimes people won't realize what's going on with them, but family and friends do."
Jacobs says lack of knowledge is often at the root of stigma surrounding depression and mental health issues. "Depression is not a weakness. It's a biologic condition that tends to run in families, affects women more than men, it affects people of all economic strata. During times of stress there can be an increase in incidence ... but it's not because a person is weak."

Foods With Vitamin D

Salmon 

There are a number of seafood options with a hearty dose of vitamin D. Salmon is high on the list; three ounces of canned sockeye clocks in at nearly 650 IUs, more than you need in one day. And three ounces of fresh sockeye has almost 450 IUs.

Canned Tuna 

Three ounces of light tuna canned in water packs 154 IUs, nearly a third of your daily recommended intake. Tuna packed in oil contains even more vitamin D, but be aware that oil means more fat.

Sardines 

Another canned option is sardines. Two of the little fish pack 46 IUs, about 13 percent of your daily recommended value.

Egg Yolks 

One large egg yolk contains 37 IUs of vitamin D. Eggs are also a great source of protein, and while, yes, they do contain dietary cholesterol, they haven't been linked with an increased risk of heart problems -- so go ahead and make 'em sunny side up.

Cheese 

A slice of Swiss contains about 6 IUs and is less processed (and contains less sodium) than a cheese like American, Fitness magazine reported. A cup of ricotta cheese has 25 IUs, but we'd suggest a smaller amount, since it's also high in fat.

Beef Liver 

Three ounces of liver contains 42 IUs of vitamin D, and while it might not be the first thing you reach for, liver also happens to be a good source of iron.

Mushrooms 

Certain fungi, when exposed to more sunlight, or to indoor ultraviolet light, can contain beneficial levels of vitamin D. Since most mushrooms are grown in the dark, check for sun-grown brands at a store near you.

Vitamin D Foods: The Best Natural Sources To Add To Your Diet

While you probably know that the body produces vitamin D when exposed to sunlight, there are also other ways to get the crucial nutrient.

However, there are only a handful of foods that contain the nutrient naturally, part of the reason why only about 20 percent of our vitamin D comes from our diet, according to WebMD.

Most of the vitamin D that we do get from the foods we eat comes from fortified foods, according to the Office of Dietary Supplements, like orange juice, milk and cereal.

Vitamin D increases calcium absorption -- which is why those fortified picks come with a hefty dose of both.

It also promotes healthy skin and may even fight depression
.
Some people opt to take vitamin D supplements to reach the 600 International Units (IUs) recommended for most adults. (As many as 4,000 IUs a day may still be safe, Scientific American reported, and could provide even greater health benefits.)

But, especially as the days get shorter, it becomes harder to spend time soaking up the sun, and you shouldn't spend too much time sunscreen-free anyway. To get the most vitamin D from your diet possible, try adding these natural sources to your meals today.

Fitness Motivation Tricks

The ability to go up to my fifth-floor walkup without feeling winded!
-- Amanda L. Chan, News Editor

My fitness motivation is endorphins!
-- Gina Ryder, Community Manager

I visualize my cells repairing, recycling and rejuvenating themselves and it makes me feel like I'm actively participating in a transformation.
-- Meredith Melnick, Nutrition and Fitness Editor

debated paying $70 a month for a gym membership for a while. But now that I have one, knowing $35 is being deducted from my paycheck every pay period motivates me to go. Cheapness trumps laziness.
 -- Laura Schocker, Senior Editor

For some "me" time. It's basically the only time of the day (besides sleeping) when I don't check my phone/emails.
-- Sarah Klein, Associate Editor

To get rid of headaches and fit into skinny jeans!
-- Kate Bratskeir, Associate Editor
 

Working out makes me feel comfortable in my body. I find feeling good and looking good translate to bolstering confidence in other aspects of my life.
-- Alana B. Elias Kornfeld, Executive Health Editor 
 

It helps me keep a positive outlook [and with] physical/emotional/spiritual well being.
-- Dr. Patricia Fitzgerald, Wellness Editor
 

When I'm tempted to give up on a run, I imagine there's an attractive man, often Leonardo DiCaprio, waiting for me at the "finish line"!!
-- Anonymous staff appreciator of mid-90s teen heart throbs

Foods That Lower Stroke Risk

Chocolate 

A Swedish study in the journal Neurology showed that eating chocolate is linked with a lower risk of stroke in men. The study, which included 37,103 men, showed that men who ate the most chocolate in the 10-year study had a 17 percent lower risk of stroke, compared with those who didn't report eating any chocolate during that time period.

Whole Grains 

Eating lots of whole grains could help to lower risk of ischemic stroke for women, according to a study in the Journal of the American Medical Association. The findings showed that women who ate the most whole grains in the study (like the amount you'd get by eating two or three whole grain bread slices every day) had a 30 to 40 percent lower stroke risk, compared with women who ate the fewest whole grains in the study (like the amount you'd get by eating just a half-slice of whole grain bread every day), according to ABC News.

Citrus Fruits 

An antioxidant found in citrus fruits could help to lower risk of stroke in women, according to a study of 70,000 women earlier this year in the journal Stroke.

Researchers from Harvard Medical School and Brigham and Women's Hospital found that women who consumed the most flavonoids over a 14-year period had a 19 percent lower risk of stroke than the women who consumed the fewest flavonoids during that time period.

Antioxidants 

 While antioxidants aren't exactly a food on their own, fruits, vegetables and whole grains that are rich in them are linked with a lower stroke risk for women. Research published in the journal Stroke: Journal of the American Heart Association showed that women with no heart disease history who consumed the most antioxidants from food had a 17 percent lower risk of stroke, and women with a heart disease history who consumed the most antioxidants from food had a 57 percent decreased risk of hemorrhagic stroke.

 The researchers, from the Karolinska Institute in Sweden, speculated that the protection comes from antioxidants' ability to stop inflammation and oxidative stress in the body by neutralizing harmful free radicals. Antioxidants can also help to reduce blood clots and lower blood pressure and decrease inflammation, according to the American Heart Association.

Low-Fat Dairy

Consuming low-fat dairy could help to lower the risk of stroke, according to a Stroke study. The research showed that the adults who consumed the most low-fat dairy over a 10-year period had a 12 percent lower risk of stroke compared with those who consumed the least low-fat dairy over the time period.

"It is possible that vitamin D in low-fat dairy foods may explain, in part, the observed lowered risk of stroke in this study because of its potential effect on blood pressure," study researcher Susanna Larsson, Ph.D., associate professor of nutritional epidemiology at the Karolinska Institutet, said in a statement.

Magnesium-Rich Foods

Foods loaded with magnesium -- like beans, nuts leafy greens and whole grains -- are linked with a lower risk of ischemic stroke, WebMD Reported. The findings, published in the American Journal of Clinical Nutrition, showed specifically that for each 100 milligrams of magnesium consumed each day, ischemic stroke risk went down by 9 percent.

Fish

Making sure to eat some fish every week could help to lower risk of stroke, according to a review of studies published in the journal Stroke. Reuters reported on the study, which showed that eating fish several times a week was linked with a lower risk of stroke, compared with non-fish eaters.

"I think overall, fish does provide a beneficial package of nutrients, in particular the omega-3s, that could explain this lower risk," Dariush Mozaffarian, an epidemiologist at the Harvard School of Public Health, whose research was part of the Stroke analysis, told Reuters.

Stroke Affecting More Young People, Study Finds

Strokes are hitting at a younger age, according to a new study published in the journal Neurology.

Researchers from the University of Cincinnati College of Medicine found that the average age at which a person experiences a stroke fell to 69.2 in 2005, from 71.2 in 1993/1994.

"The reasons for this trend could be a rise in risk factors such as diabetes, obesity and high cholesterol," study researcher Dr. Brett Kissela, M.D., said in a statement. "Other factors, such as improved diagnosis through the increased use of MRI imaging may also be contributing. Regardless, the rising trend found in our study is of great concern for public health because strokes in younger people translate to greater lifetime disability."

The study included 1.3 million people who lived in the greater Cincinnati and northern Kentucky region during 1993/1994, 1999 and 2005.

Researchers found that the number of people younger than 55 who experienced their first stroke during that time period increased to 19 percent in 2005, from 13 percent in 1993/1994.

Plus, the stroke rate among 20-to-54-year-olds increased between the beginning and end of the study; among Caucasians, strokes rose to 48 for every 100,000 people in 2005, compared with 26 strokes for every 100,000 people in 1993/1994. For African-Americans, strokes increased to 128 for every 100,000 people in 2005, compared with 83 strokes for every 100,000 people in 1993/1994.

"Among the young, the increase in incidence suggests an unknown and potentially daunting future trajectory," wrote Drs. Sally Sultan, M.D., and Mitchell S.V. Elkind, M.D., in an accompanying editorial. "Replication of these findings in other U.S. populations and internationally is crucial, and future studies will need to account for potential temporal trends in diagnostic testing while also teasing out causative factors."

The findings follow a recent study in the journal Annals of Neurology, showing that hospitalizations for ischemic stroke have gone up by 37 percent from 1995 to 2008 among people between ages 15 and 44.
Want to lower your risk of stroke? Controllable risk factors include blood pressure and cholesterol, alcohol and tobacco use, obesity, physical activity and diabetes status, according to the National Stroke Association.

And check out our slideshow of foods that have been shown in studies to be associated with a lower stroke risk: