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Ebola: Zmapp effective in macaques (rhesus monkeys)

Featured post via Medpage Today (29:08:2014)
By Michael Smith
A controversial cocktail of Ebola antibodies was safe and highly effective in saving the lives of rhesus macaques, even as the animals neared death from the virus, researchers reported.

The medication, dubbed ZMapp, saved all 18 animals in a study, even when they were given the first of three doses 5 days after infection, when the clinical signs of disease were apparent, according to Gary Kobinger, PhD, of the Public Health Agency of Canada.

The antibody cocktail has been used several times, on a compassionate basis, to treat people during the current West African outbreak. That use has been controversial because, among other issues, the medication has had no formal tests in humans.

Also, because the supply was limited, questions arose as to which patients were allowed to receive the compassionate treatment. Two were American healthcare workers who were already receiving top-level care.

Kobinger said the compassionate use was not designed as a study and it's difficult to know what effect the medication had. Nevertheless, "it's going to be very important to see what comes out of that compassionate use in humans," he told reporters in a media briefing.

What is clear, he and colleagues reported in Nature, is that the ZMapp cocktail can completely reverse the effects of Ebola infection in macaques, even when animals are very sick and would ordinarily die within 3 days.

On average, Kobinger said, macaques given a lethal dose of Ebola die within 8 days of infection. He and colleagues treated animals with the ZMapp product starting 3, 4, and 5 days after infection and saved all of them.

In such experiments, he told MedPage Today, the animals usually have virus in the blood and clinical signs of disease, such as fever, by day three "and definitely by day five."

The 5-day delay before successful treatment is the longest that has ever been observed, Kobinger said.

Kobinger added the antibody cocktail had no apparent adverse effects, either in healthy animals or in those who recovered and were given a fourth dose later.

"We have never seen any (adverse effects) in nonhuman primates," he said.

But he cautioned that the study was conducted in animals, so that effects in humans could well be different. Among other things, Kobinger said, human exposure is inadvertent, with different doses in different patients, so that responses vary.

For that reason, it's important to study safety and effectiveness in people, although "testing the latter is clearly difficult," commented Thomas Geisbert, PhD, of the University of Texas Medical Branch at Galveston.

Geisbert and colleagues have been studying small interfering RNA molecules as treatments for hemorrhagic fevers and last week reported data on a product aimed at Marburg virus.

In a Nature article accompanying the Kobinger report, Geisbert argued that a range of interventions is needed to control Ebola in the future, including antibodies, small molecules, and vaccines, many of which are under development.

An important factor might be money: "In the long run, the manufacture of ZMapp could require investment in infrastructure for making monoclonal antibodies at an industrial scale -- assuming that funding is available to pay the production costs," Geisbert concluded.

A clinical trial of the ZMapp product could be under way in early 2015, Kobinger said, although he noted that's up to the U.S. company that has licensed the medication, Mapp Biopharmaceuticals of San Diego.

However, an experimental Ebola vaccine will enter phase I clinical trials next week, the National Institute of Allergy and Infectious Diseases said Thursday. It's the first of several early stage trials of vaccine candidates, the agency said, that will evaluate safety and immunogenicity in healthy volunteers.

But even if those trials show the drugs are safe and immunogenic, it would still be some time before they could be used, even on an emergency basis, institute Director Anthony Fauci, MD, earlier told MedPage Today.

Meanwhile, the outbreak in West Africa continues to rage, with the World Health Organization reporting 3,052 probable, confirmed and suspect cases, with 1,546 deaths.

The outbreak is the largest in history, both in numbers and geographical extent, and shows no signs of flagging, the WHO reported. The agency noted that more than 40% of cases have occurred within the past 21 days, although most are concentrated in a few places in the four affected countries -- Guinea, Liberia, Sierra Leone, and Nigeria. (A case in neighboring Senegal, the country's first if confirmed, was reported Friday.)

The WHO has said that reported cases are very likely an underestimate, since some people do not seek medical attention. The agency also said the toll could go as high as 20,000 cases before the outbreak comes under control.

A separate outbreak appears to be under way in the Democratic Republic of Congo, a country in Central Africa formerly known as Zaire where Ebola virus was first identified.

Between July 28 and Aug. 18, the WHO reported, 24 suspected cases of hemorrhagic fever, including 13 deaths, have been reported, but neither the index case nor her contacts have a history of travel to West Africa.

Samples are being tested to confirm that the disease was caused by Ebola and, if so, to identify the strain.

There are five species of Ebola virus, including the Zaire species that caused the first known outbreak in the 1970s and which is responsible for the current West Africa outbreak.

Kobinger and colleagues said they tested their cocktail against the Kikwit strain of the Zaire species, which was isolated after a 1995 outbreak in the Democratic Republic of Congo and is used as a reference strain in research.

But lab tests of ZMapp against the Guinea variant involved in the current outbreak showed the medication had comparable or even slightly better binding kinetics than it does against the Kikwit strain, Kobinger said.

As well, he said the investigators have preliminary data in animals using the current circulating strain "and it performed at least as well if not better in vivo."

A next step in the research is to see how much of the drug is actually needed. The animals in the Nature study were given 50 milligrams per kilogram of body weight in three doses 3 days apart.

But Kobinger said the investigators are now trying to see if response correlates with the viral load of Ebola and if lower doses could rescue animals with a smaller amount of circulating virus.

Complicating the issue is that available supplies of ZMapp, which is grown in genetically modified tobacco plants, have been used up, he said.

Meanwhile, investigators working on the ground in the affected region suggest that Ebola mortality -- now at about 51% in the outbreak -- can be cut sharply with proper care.

"With more personnel, basic monitoring, and supportive treatment, many of the sickest patients with Ebola virus disease do not need to die," according to researchers led by Robert Fowler, MD, of the University of Toronto in Canada.

But, in an analysis in the American Journal of Respiratory and Critical Care Medicine, Fowler and colleagues paint a picture of health systems initially lacking the ability to provide that care.

For weeks, they reported, they and other health care workers in Guinea had an isolation unit and lab support for diagnosis but "no beds and no monitoring mechanism to check blood pressure, fluid balance, basic potentially life-threatening biochemical abnormalities or oxygenation."

"Thankfully we had the most important aspects of supportive care -- oral rehydration and intravenous fluids when patients could not maintain oral intake," Fowler and colleagues added.

As critical care specialists know, they said, the key to successful supportive care is "aggressive prevention of intravascular volume depletion, correcting profound electrolyte abnormalities, and preventing the complications of shock."

It "can and should be applied in both resource-constrained and resource-rich settings," Fowler and colleagues argued, and could cut the mortality of Ebola sharply.

Source: MedPage Today

Michael Smith
North American Correspondent

Doctors' Handwriting; Why we write the way we write

by Kayode Kuku MB;BS:
I had just finished discussing with a patient and was documenting away in my usual serious but friendly fashion (stealing glances occasionally), then the patient on her way out after receiving her prescription volunteered "Doctor , you've got a fine handwriting for a Doctor", Thanks, I simply replied in my "humbly" proud tone. It really wasn't the first time I had received such a compliment from a patient, yes it wasn't, but mind you I have also heard nurses complain about my handwriting and some patients wonder aloud, "Doctor, what have you written"?

The horrible handwriting of doctors ,as some describe it, has being widely discussed and condemned by many people outside the profession. While some have come to the conclusion that doctors learn to write in a particular unreadable way while in school , others believe that doctors deliberately write in a certain way in order to conceal the exact content of their prescription from their patients. Even though I do not agree with the myth, that doctors handwriting are terrible I have found in my years of schooling and medical practice that most doctors do not particularly pay attention to how well they write nor spend time trying to write legibly for reasons that will be mentioned shortly. That is not to say that doctors have the best of handwritings in any way, on the contrary in fact.

So the question is , why do doctors write the way they write?

Firstly, the truth is that like many individuals in other professions, some doctors do not have nice handwritings! Having said that, I must point out that many doctors develop "bad" handwritings in the course of their training and get used to it. The reason for this is that most doctors during medical school and before the introduction of softcopy lecture notes took down a ridiculous amount of notes via dictations which were usually delivered at a speed close to that of light, so needed to write fast enough in order to meet up with the pace of the lecturer as was the case during medical ward rounds as well. Our medical school training also involved several clinical examinations in which we had limited time mostly to document our history and findings, we therefore needed the ability to write shorthand or really fast, and hence legibility was sacrificed.
In practice, the average doctor has to contend with an incredibly heavy workload on a daily basis and hence invariably resorts to scribbling.

Frankly, there have been claims that the handwriting of doctors pose a genuine risk to patients as they render medical records unfit for purpose and nurses sometimes find it difficult to decipher instructions written by doctors. From the patients perspective, illegible handwriting can delay treatment and lead to unnecessary tests and inappropriate doses which in turn can result in discomfort and death. Illegible handwriting in medical records can indeed have adverse medico-legal complications.

Finally, inasmuch as some doctors are only a subpopulation of the vast majority of people in the society with poor handwritings, the talk about all doctors having bad handwritings is therefore more of a myth than a fact. It is however important that doctors take the pain to write legibly especially when it comes to important details of a medical record, investigation requests and reporting as well as prescription writing in order to avoid wastes and hazard in medical care and ensure efficient written communication with other health workers.

Medic-ALL.Inc 2014


Final Part
By Dr. Jide Akeju

The introduction of an expanded program that involves greater specialization was introduced in the USA, this is generally not a worldwide practice and only one institution in the United Kingdom offers something similar to the Doctor of Physical therapy program popular in the USA. JOHESU affiliates readily point to other climes to justify their demands. It can be deduced that the agitation for a residency program by the NSP has been copied from the USA, it is not what anyone can term as best global practice and regarded as excessive in some climes where masters or PhD programs are viewed as sufficient postgraduate training. Do the NSP have the requisite facilitators and experienced trainers to oversee a qualitative residency program or are they just copying and pasting what is practiced in another place without adequately evaluating the pros and cons?

If residency program is part of the agitations of JOHESU, which of the professional bodies are going to benefit? It is clear the NSP are going to reap significantly. The terminology “Consultant” refers in our system to specialist senior doctors who are appointed to ultimately take responsibility for patient admission and management. They are also involved in clinical training and supervision of medical students and resident doctors. Some of these individuals do have dual appointments in institutions with affiliated colleges of medicine where they also teach students outside of the clinical environment; undertake research and participate in general University duties and activities. It becomes laughable when JOHESU release a statement contesting double salaries given to honorary consultants and allegations that some doctors are so highly paid even more than university professors when in fact a few of them are university professors. The term is consistent with the British system as well as some commonwealth nations.
 It should be easy to understand why some allied healthcare workers are called consultants in the USA where the equivalent of hospital medical consultants and specialists are called “Attending Physicians”. Although Prof. Alonge appeared to support the appointment of consultants from other health workers, he did point to the fact that a discrepancy exist in the interpretation of the term as it affects both groups hence a need to clarify issues. I do not think that is exactly what the deserving members of JOHESU want. They constantly point at what doctors are enjoying and I guess it is those benefits they assume doctors are enjoying that has led to the demand. 

What is the yardstick to determine who and who is deserving of consultancy positions?

 Would it not lead to further rift within the ranks of JOHESU if certain affiliates do not benefit from the consultancy largess?

What would make the non-professional groups inherent in JOHESU undeserving of being appointed as consultants? 

Are the agitators of consultancy willing and competent to shoulder the responsibilities of patient care and the demands of such appointment? 

A hospital consultant position is not a reward for longevity nor is it like the appointment of delegates to a conference. It is not the peak of a doctor’s career, a doctor does not necessarily need to be in a residency program and become a consultant before he/ she can be regarded as successful or accomplished. We should not just simply adopt terminologies that are used in other climes and take them out of context to adopt them in our own system. Nurses have also recently pointed to the appointment of a female nurse as the US Army Surgeon General as validation of their demands.

It is really easy to be awed by such information but what many fail to do is read just a little about the woman concerned Patricia Horoho. It is clear that she did not attain such lofty heights just because of being a member of a gender or profession minority; she is a first class Lieutenant General highly trained and equipped to manage such a responsibility that entails human, material and enormous financial resources. Our people in Nigeria always clamor for equation balancing at the complete expense of competence. Should the JOHESU not demand for better funding and standardized education and training instead of striving for potentially unsustainable projects that could be deflated by politics and underfunding? A fellow named Nwaneri commented on a link to a JOHESU draft on the 20th of January 2014. The man commended the JOHESU executive for their resilience but asked when and if they would also ensure residency training for medical laboratory scientists and BSc nurses. Someone should lodge a requisition for NASU residency quickly.

I searched for a JOHESU website but could not locate any so I turned my attention for a facebook page at least. I did find three (3) affiliated to institutions in Yobe, Gombe and the Federal Medical Center Abeokuta (FMCA). The one for the FMCA had 148 members and one administrator called Otunba Tiamiyu who is also the public relations officer of the Abeokuta chapter of JOHESU. The” admin” seems to be a young man hell bent on misinforming him many members and launching constant abuse at the management and consultants of his institution. The fellow’s command of the English language and utterances is rather appalling and one can only imagine how such a man is responsible for representing the interest of any credible association that includes pharmacists and physiotherapists. He described the resident doctors as toddlers and their protest as senseless; he was reported in the Leadership newspapers (a paper that I think is sympathetic to the mission of JOHESU) on the 26th of July 2014 to say that doctors only jump at strikes to divert patients to their private hospitals in order to charge exorbitant fees. He rejoiced that the public had arisen to curb the excesses of doctors who he accused of behaving as gods. These are the kind of people who peddle all sorts of falsehood and inconsistencies about doctors and the NMA. They regularly accuse the NMA of incessant strike actions and easily forget the many occasions the JOHESU have threatened or outrightly embarked on strike actions that effectively grounded the health sector.

A quick search through Google will produce results that clearly show that the “development” of the health sector has been greatly slowed down by frequent strike actions detonated by the camp of the JOHESU. May 7, 2012; August 21, 2013; January 15, 2014: these are all dates of outright nationwide strikes embarked upon by JOHESU. They have been calling for the sack of the current Minister of health since 2011. They made this demand on the 21st of February 2011 accusing the minister of sabotaging their interests in favor of doctors. They continued with this demand in December 2012 and January 2013. This same minister is currently being hailed for enforcing the sack of resident doctors who are not contesting CMD or director positions with the JOHESU top brass. In a letter dated January 17, 2014 and addressed to the Minister of Health, JOHESU had stated that its good faith, patience and restraint to go on strike had been taken for weakness by the government. I wonder what JOHESU needs to do for the health ministry to sack all medical laboratory scientists in order to restructure the health sector.

JOHESU has claimed that the NMA have no right to negotiate labour disputes for any reason and to embark on strikes which has been supported vehemently by a few supposedly experienced public commentators as well as some journalists who through their reportage express clear partisanship and a clearly lackadaisical approach to their work devoid of intelligent research and fairness. One reporter with the leadership newspaper put up 2 headlines online in the space of less than 30minutes that referred to the same story that aimed to vilify the NMA and doctors. The same JOHESU that claims the NMA has no bargaining right with the FG constantly make reference to a 2009 bargaining agreement that was implemented for doctors but yet to be done for them. The public commentators usually mention that doctors are part of what is regarded as “essential services” that should never go on strike. In a blog post on the 25th of October 2012 titled “The Right to Strike in Nigeria and ILO Principles on the Right to Strike”; Femi Aborishade of the Polytechnic, Ibadan and center for labour studies reviews and appraises the laws guiding strike actions in Nigeria, the principles recommended by the International Labour Organization (ILO) on strike actions and how such affects Nigeria especially the drawbacks. The Committee of Experts and the Committee on Freedom of Association of the ILO appeared to justify the scope of restriction of strike action in “essential services” which was defined in 1983 as those services “the interruption of which would endanger the life, personal safety or health of the whole or part of the population”. The Committee on Freedom of Association described that essential services in the strict sense of the term depended to a large extent on the particular circumstances prevailing in a country and that a non-essential service may however become essential if a strike lasts beyond a certain time or extends beyond a certain scope, thus endangering the life, personal safety or health of the whole or part of the population. The committee considered essential services in the strict sense may be subject to major restrictions or even prohibitions; this is inclusive of the hospital sector; electricity services; water supply services; the telephone service and air traffic control. It is instructive that the ILO’s committee mentioned “hospital sector” and not medical doctors because striking doctors renders all other health care workers redundant likewise doctors left in a health sector paralyzed by absent health workers is also a waste of time and resources. Essentially services in the UK are listed as Emergency services, Armed forces, Health and social workers, Food industry; Agriculture, veterinary and animal welfare; Essential workers at nuclear sites; Water, sewerage and drainage; Fuel and energy suppliers; Public transport,  Licensed taxis; Coastguards and lifeboat crews;  Airport and airline workers; Postal, media, telecommunications; Central and local government workers; Essential financial services staff including those involved in the delivery of cash and cheques; Prison staff; Refuse collection and industrial waste;  Funeral services; Special schools and colleges for the disabled and Essential foreign diplomatic workers. 

If this nation realizes the importance of these diverse industries to the welfare of their people, why do our leaders assume they as politicians are more important that everyone else? 

They utilize divisive tactics to set sectors that ought to be in perfect harmony and operate in unison at each other’s femoral arteries while they simply embark on state funded trips to nations where doctors and health workers are well catered for to even think of strikes for checkup and definitive treatment. Workers who ought to know their services are equally as essential as what doctors provide sit perched on their moral high grounds to condemn doctors for demanding better conditions for the collective health sector while they move around without condemnation when they go on their own frequent strikes that shuts down record offices, morgues, theatres, pharmacies, stores, oxygen supply and wards amongst others. These frequent strikes are generally assumed to be doctors’ strike by the average visitor to the hospital. The mischievous members of JOHESU leverage on this misconception to divert the responsibility from themselves towards doctors instead.

Nigerians have to arise and make concrete demands from their government to improve their welfare. They should not just wallow in the mud and take just whatever crumbs the FG throws at them. The funds meant for developing the health sector to international standards are constantly being squandered and those who ought to know better have chosen not to be enlightened enough to ask the relevant questions and have offered themselves with the associations they represent willingly or otherwise to be tools in the hands of politicians to perpetually impoverish Nigerians

The story in the book of 1kings chapter 3 tells the story of 2 characters; prostitutes who had babies. One woman canvassed for the living baby to be split down the middle while the other only wanted the integrity of the baby. The king in his wisdom judged rightly and awarded the baby to the true mother. The NMA is asking for the status quo to be maintained while JOHESU wants what they deem are their rights and privileges. This is not to say doctors are immune to blame in all that has transpired but the truth is that the things demanded for by the JOHESU if granted would largely plunge the health sector into further crises that may not even involve the NMA. The Nurses, pharmacists and physiotherapists would become consultants; directors would emerge and then a number of the “patch patch” members would be left stranded or with crumbs. The pharmacists and physiotherapists know that they cannot embark on any effective strike to get their desired consultancy status and residency programs without the foot soldiers that would lock the doors and grind federal institutions to a halt. These unfortunate ones will realize albeit too late that they were only used and deceived with promises of better welfare packages and wage grade level increases. Some of them may never get to those grade levels by virtue of their limited educational qualifications and poverty of additional training irrespective of the years of service they offer.

The FG approved huge benefits and amnesty for reportedly surrendered militants from the Niger-Delta region. Some of these individuals have been widely reported in the local media to be on training or academic programs overseas. This is not entirely true as many Nigerians from a certain geopolitical region of Nigeria favored by the incumbent have flooded choice institutions across the world for undergraduate degrees in the stead of these militants and to the detriment of the nation’s tertiary educational sector. It is shocking that Nigerians are unmoved by the nonchalance of the FG to ensuring equity and providing even good facilities within the country. It is not surprising that government runs like normal despite the onslaught of misguided insurgents in the northeast and the over 130days of secondary school girls stranded in captivity. It is baffling that some Nigerians find it convenient to tolerate the idea of the President Jonathan's reluctance or refusal to visit his troops in the north east of Nigeria despite having the resources to do so in a flash. 

Why do some Nigerians who are supposedly educated find it very appropriate to berate doctors who insist on certain minimum standards before the strike is called off or before moving all out against the Ebola scourge? For them and some health workers, it is all about a Hippocratic Oath they seem to know nothing about. Nurses also have their oath but conveniently forget it when it comes to vilifying doctors. Is it only doctors that take oaths before embarking on their assignments? Did President Jonathan recite a poem at his inauguration?

Dr. Jide Akeju 
Senior Resident

Medic-ALL.Inc 2014


Continued from PART 1
By Jide Akeju

The 5 affiliate lions that make up the JOHESU “voltron” are: Medical and Health workers Union of Nigeria (MHWUN); National association of Nigerian Nurses and Midwives (NANNM); Senior staff association of Universities, Teaching Hospitals and associated Institutions (SSAUTHRIAI); Nigeria Union of Allied Health Professionals (NUAHP) and the Non Academic Staff Union of Educational and Associated Institutes (NASU). Of these 5 unions, only 3 are listed as written above amongst the 43 NLC affiliates I counted on the NLC website. There is no union like NUAHP and the closest union to SSAUTHRIAI is SSANU which represents the senior staff association of Nigerian Universities. In a draft released by the JOHESU to protest the non-inclusion of any of their members by the FG to the recently concluded confab, the leadership urged the president to urgently include members of the professional bodies in JOHESU at least. 

They mentioned the Association of Medical Laboratory Scientists of Nigeria (AMLSN), Pharmaceutical society of Nigeria (PSN) and the NANNM as potential sources of nominees for the national conference. The PSN, AMLSN and the Nigeria society of Physiotherapist are supposed to be members of the NUAHP together with some unspecified professional groups. If the NUAHP is not listed in the registry of the NLC as seen on the website (except they are a recent addition), how are they part of JOHESU or are they the ones referred to as the Assembly of Healthcare professionals on the JOHESU letter head? Is the SSAUTHRIAI an amalgamation of the SSANU and the Academic Staff union of research institutions (ASURI)? These issues with nomenclature and combinations greatly confuse me and their legality is debatable. How are the Non Academic staff unions of health institutes separated from those of education and the “associated” ones?

How has this heterogeneous community continued to exist and present a seemingly united front in their arguably misguided struggle? I want to believe that some more dominant members of this “Frankenstein” are using their vantage positions to pursue selfish agendas at the same time of misinforming their numerous followers and inciting the public against doctors. The head of JOHESU is a certain Ayuba Wabba who is also the head of the MHWUN and also doubles as the National Treasurer of the NLC. Dr. Ayuba P. Wabba is listed on LinkedIn as an Environmental Health Officer at the Ministry of Health in Borno state. This is the fellow who has been mandated to lead the JOHESU alliance to achieve all sorts of demands that range from skipping of CONHESS grade levels, consultancy appointments to “deserving” members, directors and membership of hospital boards; they also want the termination of illegal posts of deputy chairman medical advisory committee, establishment of residency programs for other health professional bodies  and a special entry scale for intern medical laboratory scientists amongst many other demands. The recent interview granted by the Chief Medical director of the University college hospital (UCH) Professor Alonge seems to suggest that the consultant orthopaedic surgeon is supportive of the clamor for consultancy status by other healthcare professionals. The JOHESU members have jumped on this to scream vindication and forget so easily that the man who has voiced support to their demand is also the one guilty of appointing several senior doctors as DCMACs in UCH which they regard as completely illegal. The JOHESU through its many affiliates have rained insults and derogatory remarks on doctors irrespective of the ranks of the doctors concerned. Their usual rhetoric is always about “what doctors are enjoying” at their expense. I wonder if house officers, medical officers or resident doctors are the ones getting appointed as DCMAC or directors. If resident doctors are insisting on better funding for the health sector, how does that translate to reducing the hazard or uniform allowance of records officers, morticians or nurses? They have had several meetings with government representatives especially the ministers of health and labour where promises were made to pacify them. These promises have been repeatedly broken and one wonders how gloating over the sack of doctors by the same FG that has deceived them translates to their demands being fully met. The president of the Nigeria society of physiotherapy (NSP), Oyewumi Taiwo in a press release on the 31st of July 2014 condemned the NMA for embarking on an illegitimate strike and described the venture as a “cheap ego trip” also saying that the NMA has failed in leadership. How has the NMA failed in leadership? 

Does the NMA nominate who becomes the minister of health or the medical directors of hospitals? 

Is the NMA actively consulted with respect to policy issues regarding national healthcare delivery?

The minister of health that has overseen the sack of the bulk of doctors currently in the system must be a strong member of JOHESU just like the many Chief medical directors who refuse to implement directives that are meant to favor doctors on their books. The minister of health that deceived JOHESU is the same person that NMA do not trust. Information on the website of the NSP indicates that the onset of a residency program for physiotherapists in Nigeria is imminent.

They hope to start with seven specialties: Cardiopulmonary physiotherapy, Community physiotherapy, Neurophysiotherapy  and mental health; Orthopaedic physiotherapy, Paediatric physiotherapy, Sports physiotherapy and Women’s health similar to what is obtainable in the United states where majority of their physical therapy doctorate programs have ten specialties Cardiovascular and Pulmonary, Clinical Electrophysiology, Geriatrics, Neurology, Orthopaedics, Pediatrics, Sports, Women's Health, and Wound Care. Physiotherapy was a 4year course in Nigeria until the late 1990s when it was increased to 5years; about the only country in the world where the basic degree is 5years. Most nations offer 2, 3 or 4 year programs. The introduction of an expanded program that involves greater specialization was introduced in the USA, this is generally not a worldwide practice and only one institution in the United Kingdom offers something similar to the Doctor of Physical therapy program popular in the USA. JOHESU affiliates readily point to other climes to justify their demands. It can be deduced that the agitation for a residency program by the NSP has been copied from the USA, it is not what anyone can term as best global practice and regarded as excessive in some climes where masters or PhD programs are viewed as sufficient postgraduate training. Do the NSP have the requisite facilitators and experienced trainers to oversee a qualitative residency program or are they just copying and pasting what is practiced in another place without adequately evaluating the pros and cons?

Concluded in the Final Part

Dr. Jide Akeju
Senior Registrar

Ebola: Health Workers , the Biggest Losers

Medic-ALL (26:08:2014)
The World Health Organization(WHO) on Tuesday said that the deadly Ebola outbreak in West Africa has been unprecedented in many ways. A high proportion of healthcare workers are among those infected with the virus. 

So far, over 240 healthcare workers, including doctors and nurses, have contacted the disease in Guinea, Liberia, Nigeria, and Sierra Leone and over 120 have died.

According to the WHO, the virus has taken the lives of doctors in Sierra Leone and Liberia, depriving these hard-hit countries not only of experienced medical care but also of inspiring national heroes.

The UN health agency noted that shortage of personal protective equipment or its improper use, too few medical staff to cope with such a large outbreak and working beyond the number of hours recommended as safe contributed to the high proportion of infected medical staff. 

"In many cases, medical staff are at risk because no protective equipment is available, not even gloves and face masks. Even in dedicated Ebola wards, personal protective equipment is often scarce or not being properly used," it said. 

In the past, some Ebola outbreaks became visible only after transmission was amplified in a health care setting and doctors and nurses fell ill. However, once the Ebola virus was identified and proper protective measures were put in place, cases among medical staff dropped dramatically.

Moreover, many of the most recent Ebola outbreaks have occurred in remote areas, in a part of Africa that is more familiar with this disease, and with chains of transmission that were easier to track and break.

The current outbreak is different. Capital cities as well as remote rural areas are affected, vastly increasing opportunities for undiagnosed cases to have contact with hospital staff. Neither doctors nor the public are familiar with the disease. Intense fear rules entire villages and cities.

Several infectious diseases endemic in the region, like malaria, typhoid fever, and Lassa fever, mimic the initial symptoms of Ebola virus disease. Patients infected with these diseases will often need emergency care. Their doctors and nurses may see no reason to suspect Ebola and see no need to take protective measures.

Some documented infections have occurred when unprotected doctors rushed to aid a waiting patient who was visibly very ill. This is the first instinct of most doctors and nurses: aid the ailing.

The heavy toll on health care workers in this outbreak has a number of consequences that further impede control efforts.

It depletes one of the most vital assets during the control of any outbreak. WHO estimates that, in the three hardest-hit countries, only one to two doctors are available to treat 100,000 people, and these doctors are heavily concentrated in urban areas.

It can lead to the closing of health facilities, especially when staff refuse to come to work, fearing for their lives. When hospitals close, other common and urgent medical needs, such as safe childbirth and treatment for malaria, are neglected.

The fact that so many medical staff have developed the disease increases the level of anxiety: if doctors and nurses are getting infected, what chance does the general public have? In some areas, hospitals are regarded as incubators of infection and are shunned by patients with any kind of ailment, again reducing access to general health care.

The loss of so many doctors and nurses has made it difficult for WHO to secure support from sufficient numbers of foreign medical staff.

Nigeria, last week lost a Consultant Endocrinologist who was one of the senior health workers who attended to the country's patient zero while he was on admission. She was said to have forced the patient back to his bed when he once attempted to escape from the hospital.

On Monday, Liberia's deputy chief medical doctor Abraham Borbor died of Ebola. 
Since the beginning of the international response to the outbreak in March, the WHO has deployed nearly 400 people from across the organisation and from partners in the Global Outbreak Alert and Response Network to help respond to the disease in four West African countries. 

The toll in Guinea, where the epidemic started, is 406, while in Sierra Leone, 392 have succumbed to the haemorrhagic fever. Nigeria has witnessed five deaths so far. 

The outbreak of Ebola began in Guinea in December 2013, leading to an epidemic in west Africa after it spread to Liberia, Sierra Leone and Nigeria.

Ref: WHO media centre

Medic-ALL.Inc 2014


By Dr. Jide Akeju
16Then came there two women, that were harlots, unto the king, and stood before him. 17And the one woman said, O my lord, I and this woman dwell in one house; and I was delivered of a child with her in the house. 18 And it came to pass the third day after that I was delivered, that this woman was delivered also: and we were together; there was no stranger with us in the house, save we two in the house. 19 And this woman's child died in the night; because she overlaid it.20 And she arose at midnight, and took my son from beside me, while thine handmaid slept, and laid it in her bosom, and laid her dead child in my bosom. 21And when I rose in the morning to give my child suck, behold, it was dead: but when I had considered it in the morning, behold, it was not my son, which I did bear. 22And the other woman said, Nay; but the living is my son, and the dead is thy son. And this said, No; but the dead is thy son, and the living is my son. Thus they spake before the king.
23 Then said the king, The one saith, This is my son that liveth, and thy son is the dead: and the other saith, Nay; but thy son is the dead, and my son is the living. 24 And the king said, Bring me a sword. And they brought a sword before the king. 25 And the king said, Divide the living child in two, and give half to the one, and half to the other. 26 Then spake the woman whose the living child was unto the king, for her bowels yearned upon her son, and she said, O my lord, give her the living child, and in no wise slay it. But the other said, Let it be neither mine nor thine, but divide it. 27Then the king answered and said, Give her the living child, and in no wise slay it: she is the mother thereof. 28 And all Israel heard of the judgment which the king had judged; and they feared the king: for they saw that the wisdom of God was in him, to do judgment.”  1kings3:16-28 (KJV Bible)

When the news about the sack of all resident doctors was eventually confirmed, many Nigerians took to social media to express their unwavering support for the definitive judgment meted out to the striking, arrogant and greedy doctors who had failed to respond to the Ebola virus outbreak. Among those who joined the bandwagon of solidarity with the Nigerian emperor were other health workers under the banner of the “Assembly of Healthcare Professionals and Joint Health Sector Unions (JOHESU)” some of who said the resident doctors were deserving of such a drastic decision after embarking on a prolonged “illegal” strike action. A sensible individual who claims to be concerned about the happenings in the Nigerian health sector ought to ask him/herself a very critical question; “How does one justify the sacking of resident doctors who are affiliate members of the parent body called the Nigerian Medical Association (NMA) for a strike declared and enforced by the parent body?”

Who on earth are JOHESU that seem to have the Health Ministry and the Government by the gonads?

The creation of this hydra-headed structure still remains a mystery to me despite a lot of effort to trace its point of origin and insertion. This body seems to have perfected the art of ”shapeshifting” believed to only exist in folklore and mythology. Like the Marvel comics character “Mystique”, this amorphous organization has found a way to appear as whatever they wish to any group of people, peddling falsehood and retaining their ”integrity” in the process. They were out with a press release shortly after the NMA called for a nationwide strike on the 1st of July 2014 in which they condemned the strike and declared it illegal. By the 17th of July, they had sued the NMA and challenged the legal right of the association to declare a strike when it was not a part of the recognized trade unions in Nigeria and therefore did not have a right to negotiate any trade issues with the Federal government (FG). If the NMA does in fact have no right to seat at the table with the FG, who then is responsible for negotiating on its behalf?

The Nigerian Labour Congress (NLC) is described on its website as the only national federation of trade unions in the country with “fundamental aims and objective to protect, defend and promote the rights, well-being and the interests of all workers, pensioners and the trade unions; to promote and defend a Nigerian nation that would be just, democratic, transparent and prosperous and to advance the cause of the working class generally etc.” There are about 16 listed ways of achieving these for “all Nigerian workers” both in the public and private sector all clearly stated on the website. The congress has about 43 affiliate bodies listed on its website with their relevant addresses and contacts. It is mentioned that the umbrella body is aware of the existence of a massive and dynamic informal sector of the economy which is currently not a member of the congress; a status not also extended to the military and paramilitary services as well as civil establishments that carry out duties classified by law as essential. The only example given under civil establishments was the central bank of Nigeria. The JOHESU take pride in their ability to hold negotiations with FG on labour disputes citing that all 5 affiliate members are also members of the NLC and Trade Union congress of Nigeria (TUC). I have to agree with a column written by Ibrahim Idris about 7months ago in “Premium Times” where he described JOHESU as illegal. A quick look at the current letter headed papers on which their communiques are printed would reveal 5 logos by the left side margin vertically oriented. One communique released on the 6th of January 2014 reveals a logo at the top (consisting of the images of 2 tablets and one capsule surrounded by the acronym) with the title as “Assembly of Healthcare Professionals and Joint Health Sector Unions”; another released on the 17th of January 2014 has only the expanded JOHESU at the top. Subsequently, the letter head has remained as “Joint Health Sector Unions and Assembly of Healthcare Professionals”. I really wonder how such a “dynamic” organization gets to command the attention of the FG.

To be Continued....

Dr Jide Akeju BDS
Senior Registrar

NMA Strike: New Salary structure to take off in Jan 2015

The House of Representatives in Nigeria on Monday disclosed that the new salary structure for doctors would be reflected in the 2015 budget and takes effect from January 2015.

Ndudi Elumelu, chairman, House Committee on Health, gave the assurance while reacting to the resolution of the Nigerian Medical Association (NMA) to suspend the 55-day old nationwide strike on Sunday.

According to him, the parties during the reconciliatory meetings attended by Federal Government’s team resolved “that the Federal Ministry of Health will grant the request of NMA for a new circular as demanded by NMA.

“That the Federal Government shall pay two months’ salary arrears to members of NMA on or before August 31, 2014; that balance of salary arrears would be reflected in the 2015 budget and paid to members of NMA.

“That the new salary structure of medical doctors would be reflected in the 2015 budget and medical doctors will begin to get the new salary structure effective from January 2015.”

During the overview of the suspended industrial action declared by the association, Elumelu stressed the need for the Federal Government and organised labour unions to honour various agreements reached in the bid to forestall future strike action and ensure industrial harmony in various sectors of the nation’s economy.

“One of such lessons is the need to obey agreements. The law is pacta sunt servanda meaning: agreements must be obeyed. If parties had obeyed previous agreements executed between NMA and representatives of the Federal Government, the strike would have been averted. The lesson to learn here is that we must at all times obey contents of agreements freely entered into in order to avert crisis,” Elumelu said.

The lawmaker, who expressed displeasure over the unpatriotic attitude of the association towards the plight of the citizens in the face of the outbreak of Ebola virus and other life-threatening diseases that claimed the lives of several Nigerians during the strike period, noted that NMA “acted contrary to the revered oath of the medical profession and the code of medical ethics (2004) for medical dental practitioners in Nigeria.

“The leadership of NMA has been described as unpatriotic even by other Nigerian doctors as well as members of the public in view of various health challenges confronting the nation and the scourge of Ebola virus disease, which erupted during the strike period. Patriotic Nigerians both home and abroad have passionately condemned the action of the current leadership of the NMA. Comments have been heard and read from various media platforms concerning the …actions of the NMA president,” he said.

Source: Business Day

AS-AS Couple: Prenatal Diagnosis Option


Today we celebrate the 10 year anniversary of the World Sickle Cell Day. It is a day to raise public awareness of sickle cell disease, and shed light on the challenges experienced by patients and their families and caregivers. In this article we briefly discuss the sickle cell disorder and trait

Pre-Natal Diagnosis
With awareness growing about the attendant consequences of having a child with the sickle cell disorder (SS) in this present age, many young people with the AS or AC genotype continue to take precautions regarding the genotypes of their spouses, as parents who have the benefit of hindsight counselling against their sickle cell trait (AS) children getting involved with their type and religious organizations putting in place strict laws including mandatory genotype testing before joining couples.

Many knowledgeable couples who happen to carry the sickle cell trait however still end up together and look forward to having kids without the sickle cell disease and thankfully scientists continue to work tirelessly to add to the present medical options available; Prenatal diagnosis for genotype, In-vitro fertilization and Bone marrow/Stem cell transplant. These options have been proving beneficial to many of such couples and continue to become increasingly available to all.

Prenatal Diagnosis
Prenatal diagnosis is a procedure done in the first trimester of pregnancy to determine the genotype of the foetus in-utero. Couples with the AS trait who are at risk of having a baby with sickle cell disease are offered this service at about 8th weeks of gestation after being screened and counselled.  It is an ultrasound guided procedure and placental samples are taken from the fetus. Complications that can arise from the procedure include pain, bleeding, and rarely miscarriage. 

Sickle Cell for your Information
Sickle cell disease is an autosomal recessive condition. sickle cell disease is a hereditary blood disorder. If both you are your spouse are AS genotype then you are both carriers of the abnormal gene. During each pregnancy you will have a 1 in 4 (25%) chance of having an affected child SS genotype, a 1 in 4 (25%) chance of a normal child AA genotype, and a 1 in 2 chance (50%) of a carrier child AS genotype. 

The availability of direct prenatal testing can provide a definite answer, rather than a statistical estimate, on whether a foetus has sickle cell disease. The information from prenatal testing may be used to consider different reproductive options. You are advised referral to a geneticist or obstetrician that specializes in prenatal diagnosis.

Medic-ALL.Inc 2014

Prenatal Diagnosis: This service is available at various centers across the world

ALS & The Ice Bucket Challenge

Medic-ALL (24:08:2014):
The "Ice-bucket challenge" for some weeks has being making the waves in the social media world. From athletes to movie-stars to politicians and millions of ordinary people all over the world, no one has been left out of this initiative to raise money for amyotrophic lateral sclerosis (ALS) research and awareness. 

In case you have been on some deserted island and away from the internet in the past few weeks the Ice bucket challenge involves pouring a bucket of ice water over their heads and challenging others to do same. When challenged by a friend or colleague to take up the task, you have 24 hours to either donate $100 to the cause or post a video showing yourself donating a bucket of ice on your head. You then in turn challenge 3 other people. A Former President of the United States, George W.Bush despite having said in a preamble to his video that the "task" was "not presidential" soon had a bucket of ice water dumped on his head by his wife, Laura Bush. He then went on to challenge his presidential predecessor, Bill Clinton.

Millions in Donation
The ALS Association credits Pete Frates, 29, a former Boston College baseball captain who has lived with ALS since 2012, for launching the viral sensation some 3 weeks ago. Frates and his family have been fundraisers and advocates for the ALS Association Massachusetts Chapter for a number of years.

Unfortunately, Frates' friend, Corey Griffin, 27, who was instrumental in having the ALS challenge go viral, died in a diving accident in Nantucket, MA. The accident occurred early in the morning of Aug. 16, when Griffin dove off a two-story building into the harbor. According to news reports, It happened only hours after he had raised $100,000 for the cause.

About ALS
There is no doubt that the condition deserves all the social media attention it's getting at this time, let's take a closer look at the disease ALS:

Amyotrophic lateral sclerosis (ALS), also often referred to as "Lou Gehrig's Disease," is a progressive neurodegenerative disease that affects nerve cells in the brain and the spinal cord. Motor neurons reach from the brain to the spinal cord and from the spinal cord to the muscles throughout the body. The progressive degeneration of the motor neurons in ALS eventually leads to their death. When the motor neurons die, the ability of the brain to initiate and control muscle movement is lost. With voluntary muscle action progressively affected, patients in the later stages of the disease may become totally paralyzed.

A-myo-trophic comes from the Greek language. "A" means no or negative. "Myo" refers to muscle, and "Trophic" means nourishment–"No muscle nourishment." When a muscle has no nourishment, it "atrophies" or wastes away. "Lateral" identifies the areas in a person's spinal cord where portions of the nerve cells that signal and control the muscles are located. As this area degenerates it leads to scarring or hardening ("sclerosis") in the region.
As motor neurons degenerate, they can no longer send impulses to the muscle fibers that normally result in muscle movement. Early symptoms of ALS often include increasing muscle weakness, especially involving the arms and legs, speech, swallowing or breathing. When muscles no longer receive the messages from the motor neurons that they require to function, the muscles begin to atrophy (become smaller). Limbs begin to look "thinner" as muscle tissue atrophies.

FACT: ALS is not contagious. 

It is estimated that ALS is responsible for nearly two deaths per hundred thousand population annually.

Although the cause of ALS is not completely understood, the recent years have brought a wealth of new scientific understanding regarding the physiology of this disease.

While there is not a cure or treatment today that halts or reverses ALS, there is one FDA approved drug, riluzole, that modestly slows the progression of ALS as well as several other drugs in clinical trials that hold promise. 

Importantly, there are significant devices and therapies that can manage the symptoms of ALS that help people maintain as much independence as possible and prolong survival. It is important to remember that ALS is a quite variable disease; no two people will have the same journey or experiences.  There are medically documented cases of people in whom ALS ‘burns out,’ stops progressing or progresses at a very slow rate. 

ALS Association
This is a United States based association committed to leading the fight to treat and cure ALS through global research and nationwide advocacy while also empowering people with Lou Gehrig's Disease and their families to live fuller lives by providing them with compassionate care and support. 

Barbara J. Newhouse, president and chief executive officer of the ALS Association, in a statement said that ALS Association are extremely grateful for the generosity of these donors, and for the actions of several people who initiated and spread this incredible viral effort she also states that the additional funds will help the association "think outside the box" in the fight against this disease. 


Medic-ALL.Inc 2014

NEW!!! Residency Training in Canada

Canadian Path : The Road to Residency Training in Canada 

Ohhhh Canada…. An Overview

With the current state of the Nigerian Health care system and the disheartening future outlook of the Medical profession in Nigeria, it is not a surprise that many Nigerian Doctors are looking for greener pastures elsewhere. Some of these choice places being looked at include USA, UK, Ireland, Australia and Canada.

Read More here

U.S Ebola Patients Discharged

Medpage Today 21:08:2014
Ebola patient Kent Brantly, MD -- saying "today is a miraculous day" -- has been discharged from an Atlanta hospital with a clean bill of health.

Brantly, a medical missionary working in Liberia, was airlifted to the U.S. and arrived at Emory University Hospital after coming down with the virus about 9 days earlier.

After a "rigorous course of treatment and thorough testing ... we have determined that Dr. Brantly has recovered from the Ebola virus infection," said Bruce Ribner, MD, medical director of the infectious disease unit at Emory.

"He can return to his family, to his community, and to his life, without public health concerns," Ribner told reporters.

Nancy Writepol, the other American missionary with Ebola airlifted to Emory, was discharged Tuesday, but at her request there was no announcement, Ribner said.

Brantly told reporters he was thankful to be alive and to be reunited with his family, who had returned to the U.S. from Liberia in late July as the Ebola outbreak worsened.

Two days after he put them on a homebound flight, he said, he woke up feeling "under the weather" as the first signs of Ebola infection made themselves known. As he grew weaker, he said, he and many others prayed for his survival.

"I serve a faithful God who answers prayers," Brantly said. "Through the care of the Samaritan's Purse and SIM missionary team in Liberia, the use of an experimental drug, and the expertise and resources of the healthcare team at Emory University Hospital, God saved my life."

Brantly was unable to pinpoint how he became infected, saying he and his colleagues in Liberia "took every precaution" while they were caring for Ebola patients.

Ribner said the Emory team, including five physicians and 21 nurses, is "tremendously pleased" with Brantly's and Writepol's recovery. Because there's very limited experience with treating Ebola in developed countries, he said, "we didn't know what to expect."

The recovery is "pretty gratifying."

He reiterated several times that neither patient now poses a public health threat, saying there's no evidence that recovered patients relapse, remain contagious, or can transmit the disease.

Among the criteria for pronouncing the two cured, he said, were absence of Ebola virus in the blood and symptomatic improvement for 2 or 3 days.

The two were cared for in Emory's Serious Communicable Disease Unit, which has been described as having an extraordinarily high level of clinical isolation.

But Ribner said that unit, set up in collaboration with the CDC, was only used because it was "convenient .... You don't need a special unit to take care of patients with Ebola."

In fact, he said, the choice of Emory, rather than some other U.S. hospital, was "semi-random" and largely because of its close ties with the CDC.

He said caregivers wore personal protective equipment that was consistent with CDC guidelines, including gowns and gloves. He added that workers found face shields and goggles difficult to use because of their tendency to fog up.

The key to the cures, he said, was "aggressive supportive care" at a level that is not commonly available in Africa but is widely available in the U.S.

Ribner added it's impossible to know if experimental therapies played a role. Both Brantly and Writepol were given a cocktail of Ebola antibodies, dubbed Zmapp, that had not previously been given to humans.

"We do not know whether it helped, whether it made no difference, or even theoretically if it delayed their recovery," Ribner said.

Brantly also reportedly got a transfusion of blood from a patient who survived the virus, but Ribner said the same cautions apply to that treatment.

The Zmapp antibody cocktail has also been given to two doctors and a nurse in Liberia, the World Health Organization said, and clinicians there are reporting a marked improvement in two of them.

The third patient, a physician, remains in serious condition, but has improved somewhat, the agency said in a statement. Supplies of the experimental drug are now exhausted, the WHO said.

Ribner said the Emory team learned some lessons about treating Ebola that might have an impact on the outbreak and is currently creating guidelines for care.

He noted that the West African healthcare systems "suffer a substantial lack of infrastructure" that hampers their efforts.

"We did learn a number of things ... in terms of fluid and electrolyte replacement, in terms of clotting abnormalities, and so on, which frankly our colleagues in Africa don't have the capability to detect."

However, simply knowing about those factors might help African doctors improve outcomes. "There are things you can do, even if you can't measure them," Ribner said.

The WHO says the outbreak, which began in late December, has now caused 2,473 known infections and 1,350 deaths in Guinea, Liberia, Sierra Leone, and Nigeria.

Medic-ALL.Inc 2014

Ebola Travel: South Africa bans West African incomers

BBC  (21:08:2014):
South Africa says non-citizens arriving from Ebola-affected areas of West Africa will not be allowed into the country, with borders closed to people from Guinea, Liberia and Sierra Leone.

Passenger being screened at the Kenyan airport, a common transit point for African travellers

All non-essential outgoing travel to the affected countries has been banned.
Senegal also said it was suspending flights with Ebola-affected countries, and closing the border with Guinea.
Cameroon and the Ivory Coast earlier imposed travel bans, despite World Health Organization warnings not to.
South African nationals will be allowed to re-enter the country when returning from high-risk countries, but will undergo strict screening, the health ministry said on Thursday.
Usual screening procedures are in place for those who travel between Nigeria, Kenya and Ethiopia, which have been defined as medium-risk countries.
Nigerian Airport: screening processes stepped up

South Africa has experienced two Ebola scares in recent weeks, involving passengers arriving from Liberia and Guinea, but the country has so far remained Ebola-free.
Johannesburg has one of the major transit airports, connecting southern Africa with the rest of the continent. Several airlines, including British Airways and Emirates Airlines, have stopped flights to some of the affected countries.
Meanwhile, Senegal's interior ministry announced on Friday it was closing the land borders with Guinea "once again".
Senegal shut its border with Guinea for the first time in March after the virus reached the capital Conakry.
In a statement, it said this extends to "air and sea borders for aircraft and ships from the Republic of Guinea, Sierra Leone and Liberia".
AU team
Separately, the African Union (AU) announced plans to send a special team to the four affected countries.
The six-month-long operation, involving volunteer doctors, nurses and medical personnel, will cost about $25m (£15m) and begin immediately, the AU said in a statement.
Aid workers and medical staff are most exposed to the virus, and have been most at risk of becoming infected.Two US aid workers were discharged from hospital on Tuesday, after recovering from the virus they contracted in Liberia.
The supply of the experimental drug used to treat the couple, ZMapp, has been exhausted.
As Ebola has no known cure, it is being controlled by isolating victims and those who have come into contact with them.
Liberia's attempt to prevent the spread of the virus by imposing quarantines has led to unrest.

Medic-ALL.Inc 2014

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