Nobel prize winners

Who and why these doctors won the Nobel Prize for medicine.

Lung ultrasound for pneumonia 

Lung ultrasound for paediatric pneumonia…

ISIS and Chemical Weapons-Review of NBC agents

Recent reports of ISIS using chemical weapons have been emerging from multiple sources. The main chemical threats mentioned are “mustard agents”.

The use of chemicals or biological agents in war in not new. The first use of these types of agents was in April 1915 by the Germans who used sulfur mustard in Ypres, Belgium. These agents are typically classified into one of three broad groups and go by the acronym NBC for nuclear, biological and chemical.

Here I will briefly look at chemical agents and specifically mustard and lewsite type agents after a basic review of all three types.


This is simply the deliberate spread of radioactive materials that are harmful to humans and animals. There are multiple methods to spread this radioactive material from simply placing radioactive material in a public space to using explosive devices to scatter the material. While there are multiple types of radiations including light, sound, radio waves, microwaves and heat, the chief concern here will be ionizing radiation.


This is the the use of biological agents, chiefly bacteria, viruses and some naturally derived poisons to harm humans and animals. Anthrax, Plague, Smallpox, Viral Hemorrhagic Fevers and Ricin are classic examples of these agents.


Chemical agents are broadly divided into several categories based on their mechanism of action within the body. Nerve agents, Blister or Vesicant agents, Blood agents and pulmonary intoxicants are the traditional groups and division. Examples of well know nerve agents include sarin and VX chemicals. Blister agents include mustard and lewsite while blood agents are cyanide. Pulmonary agents include chlorine and ammonia.

Mustard Agents:

Sulfur Mustard is spread either by vapor inhalation or direct contact with the liquid. Damage to the skin, eyes, airways and internal organs is common. Skin blisters and respiratory distress are most common manifestations. There is no specific treatment or antidote.


Mustard is an oily yellowish/brown liquid that generally smells like garlic or mustard. At temperatures above 100F it is a vapor hazard. Due to its oily consistency, cross contamination is a concern.

Mechanism of Action:

Mustard is absorbed and causes cell damage in 1-2 minutes after contact although clincal effects can take hours to emerge. Hours after exposure the patients will usually begin to present for medical care. There are no immediate clinical symptoms. The most common interval between exposure and symptom onset is 4-8 hours.

Clinical Effects:

Eyes are typically effected as a conjunctivitis and is dose dependent. Worse exposures produce worse symptoms. Redness and watering are typical.

Skin effects begin hours after exposure and erythema, burn and itch are common. Vesicles form and then coalesce into larger blisters.

Pulmonary effects are due to damage of the mucosa and airways. Upper airways are effected first and spread downward into the bronchioles depending on dose and exposure time. Pulmonary edema is rare but can occur.

Blood forming system effects are longer term concerns and require a significant exposure. The White Blood Cell count begins to decrease due to damage to precursor cells in the bone marrow. Lack of these cells increase susceptibility to infections.

Treatment of Mustard Type Exposure:

There is no specific treatment or antidote. Decontamination of the patient is paramount to prevent further damage from the agent. Irrigation with saline or water is important as is taking care to avoid cross-contamination. Supportive care with creams and pain control is also important management.

To learn more:

Dengue fever and Yemen Outbreaks September 2015


Aedes mosquito

A recent increase in dengue fever activity has become an serious outbreak concern in Yemen. A country that has been suffering from civil unrest and conflict, collapsed medical infrastructure and is now suffering from “an extreme spike” in dengue fever cases according to the World Health Organization (WHO) in August, 2015 means that the only winners in Yemen right now are the mosquitoes.

The epicenter of this Yemeni Dengue outbreak is the city of Taiz, located in central Yemen. The city of Taiz is on the civil war frontlines, in the middle of the conflict between the Houthi rebels from the north and the Saudi-backed fighters loyal to the exiled president Abbdu Mansour. The WHO reports 1,243 cases thus far in 2015 but on-ground intelligence estimates the number of actual cases to be almost 10 times higher.

Dengue Fever Basics

Dengue is a viral illness spread through the bite of infected mosquitoes (Aedes Aegypti). Typically a mild to moderate illness with flu-like symptoms of fever, malaise and myalgia (muscle aches), severe cases can have hemorrhagic manifestations and progress into Dengue Hemorrhagic Fever (DHF). Approx 75% of cases are asymptomatic.

Causative Agent: Dengue viruses are in the Flavavirus group and have four distinct sero-types numbered DENV-1, 2, 3 and 4. All types can cause DHF.

Prevention: Insect bite prevention with DEET and Permethrin treated clothing, bed nets and screens; destruction of mosquito breeding grounds (standing water) and control of insect vectors

Treatment: Supportive; fever control, rehydration, pain control and  blood/blood products as needed for severe cases


Looking at why the Dengue outbreak has become so severe will also show more about the damage that has been done to the country of Yemen with all the recent unrest. Dengue is spread through mosquitoes. Mosquitoes like to breed and incubate in standing water. Yemen is a country that has had its infrastructure destroyed and running water in homes is rare. Access to clean water is limited. Garbage collection services are non-existent. People are storing water in makeshift containers and water is collecting in tires, pots, canisters and cups left out as trash. This makes for a prime breeding ground to increase mosquito numbers.

Combining this increase in mosquito numbers with a loss of almost half of the medical services in the country means conditions are perfect for this outbreak. While death from Dengue or DHF is rare (approx 1%), good medical care is required to have these good outcomes.

For more information on Dengue:

Dengue in Yemen:

Social vulnerability and Ebola

An interesting look at using determinates of social vulnerability to map potential Ebola effects and outbreaks:

MNT : Ebola virus disease in Liberia

Counterfeit medicine in Africa

Counterfeit medicine is nothing new but a recent study showed just how much of a risk there was in Sub-Saharan Africa. 

Common chronic disease medicines such as statins and blood pressure medicines were shown to have over 16% with inadequate amounts of the active ingredient.

Travelers are encouraged to buy from reputable sources or simply being their own medicines from home.

African antivenom shortage

African anti-venom Fav-Afrique manufactured by Sanofi will be gone by 2016. 

The cocktail of equine derived antivenom that offers protection against the 10 most common venomous snakes in Africa was last made in 2014 and has an expiration date of 2016. No new product is currently being made.

MNT : Thousands of lives at risk from snake bites as doctors warn antivenom is running dry


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