Malaria makes a comeback,
even in the U.S.

When two cases of malaria surfaced in New Haven late last year, they were of interest to clinicians not because of any epidemiological threat, but for the treatment problems they posed. Both cases were imported, rather than transmitted within North America. Both patients had contracted malaria during visits to West Africa to visit family. One was 24 weeks pregnant and one was found to be HIV-positive.

The clinicians treating the HIV-positive patient, according to Frank J. Bia, M.D., M.P.H., professor of medicine and laboratory medicine, speaking at grand rounds in January, were concerned about the interactions between HIV infection and malaria. In the case of the pregnant patient, noted Marissa Wilck, M.D., Winchester Fellow in Clinical Microbiology, clinicians were interested in the interaction of hemoglobinopathy and malaria. Ultrasound revealed the woman’s fetus to be healthy.

A distant memory in the developed world, malaria is thriving in 91 countries (See cover story, To the vector go the spoils). In southern Asia, Africa and Latin America, malaria affects about 300 million people annually and kills as many as 1.5 million each year, mostly children. Malaria has defeated eradication efforts, which were abandoned 30 years ago in favor of control strategies. It has become resistant to synthetic cures such as chloroquine and, with increased ease of travel, threatens to reach places where it was thought to be done away with. It is not unusual to see imported cases at Yale-New Haven Hospital, Wilck said. New York City, with its large population of immigrants, Bia said, has reported cases of transmitted, as well as imported, malaria.

Western medicine first found a remedy for malaria in the 17th century, when a Jesuit missionary in Peru was cured with the bark of the cinchona tree. It was thereafter known as Jesuit’s bark or Peruvian bark. Its active ingredient was quinine.

The pathogen’s portal into the body remained a mystery until 1898, when Ronald Ross, a British physician with the India Medical Service, identified the female Anopheles mosquito as a vector. Malaria is believed to be 30 million years old, and humans are not its only vertebrate target. Other primates, even birds, have their own forms of malaria infection. 

Ultrasound provides an
alternative to amnio

Yale scientists have devised a test for fetal anemia that eliminates the risks of invasive procedures such as amniocentesis or cordocentesis. The test uses Doppler ultrasound to measure fetal blood velocity in the cerebral circulation. Anemic fetuses have a higher blood flow velocity in arteries and veins. “Invasive procedures place the fetus in unnecessary danger,” said Giancarlo Mari, M.D., associate professor of obstetrics and gynecology and lead author of the study. “In more than 70 percent of cases, the fetuses tested were either non-anemic or mildly anemic, and an invasive procedure could have been either avoided or delayed.” The study was published in the Jan. 6 issue of The New England Journal of Medicine.

Is it ever right to practice
on the dying?

Early in 1998 a student approached Lauris C. Kaldjian, M.D., HS ’91, with a question about something disturbing seen on the wards. The student, said Kaldjian, wondered if it was ethical to use a dying patient to practice inserting a femoral-vein catheter, even though the procedure offered no therapeutic value. “There was enough of a concern to do a proper study of the question,” said Kaldjian, a clinical instructor in medicine who co-directs a program on ethics for hospital residents and is pursuing a doctorate in ethics at Yale’s Department of Religious Studies. In the fall of 1998 Kaldjian surveyed 234 residents at three training programs encompassing five hospitals in Connecticut. “I was surprised that as many as a third of the respondents thought it was appropriate to use one patient for the sake of other patients,” he said. “The important thing to remember is that the people who believe this is OK are doing this for noble reasons. The question is, ‘Can one have good motivations and still be doing something that is inappropriate?’”

In a paper published in the Dec. 30 issue of The New England Journal of Medicine, Kaldjian reported that 34 percent of respondents believe it is sometimes appropriate to insert femoral-vein catheters for practice during cardiopulmonary resuscitation, 26 percent had observed such insertions and 16 percent had attempted the procedure themselves. “We don’t see any reason to doubt that results would be different elsewhere,” Kaldjian said. The dilemma, he says, is to reconcile the needs of the patient with the larger need of society to have well-trained doctors. “I would argue that, as a clinician, my first responsibility is to the patient who is immediately in front of me. We cannot use one patient to serve other patients,” he said, noting that there are alternatives to this way of training. “You learn to do this procedure on people who have to have it done.”

Breast-cancer genes
factor into treatment

Young women with breast cancer who carry either of two mutated genes may be at higher risk for a new cancer years after initial treatment, according to a study by Yale researchers. “Our findings reveal that if these women elect breast-conserving therapy—radiation and lumpectomy—there is possibly a greater risk of developing a second tumor in the conservatively treated breast,” said Bruce G. Haffty, M.D., associate professor of therapeutic radiology. The genes, BRCA1 and BRCA2, are passed from mother to daughter, and previous studies have shown that women who carry them have higher-than-normal rates of breast cancer. “Young age is often associated with BRCA abnormalities. If these women are predisposed to cancer, then trying to suppress it in some fashion would make sense,” Haffty said. The findings were published in the October issue of the Journal of Clinical Oncology. Haffty has begun a larger study, looking at up to 150 women aged 42 or younger.

Aspirin, on its own, shown to reduce heart-attack risk

An aspirin a day is as effective alone as with a powerful drug at preventing blood clotting in coronary vessels after a heart attack, Yale researchers have found. The six-year study of more than 5,000 subjects found no difference between heart-attack sufferers who used aspirin alone and those who used it in combination with the anti-clotting drug Coumadin. “There was no difference between the two groups in terms of total mortality, cardiovascular mortality, non-fatal myocardial infarction and non-fatal stroke,” said Michael Ezekowitz, M.D., professor of medicine and cardiology. Aspirin is cheaper than Coumadin and does not require monitoring. The study was presented at the American Heart Association meeting in November.

Antibody test is a reliable screen for ehrlichiosis

A collaboration between scientists at Yale and the State of Connecticut has yielded a simpler and more reliable blood test to diagnose ehrlichiosis. The disease, carried by the same deer tick that spreads Lyme disease, causes flu-like symptoms such as headache, fever and muscle cramps. It is not known if it can cause any long-term health problems. Jacob IJdo, M.D., and Erol Fikrig, M.D., collaborated with Louis Magnarelli, Ph.D., vice director of the Connecticut Agricultural Experiment Station in New Haven, in developing a test that seeks out antibodies specific to ehrlichiosis. Their findings were published in the November issue of the Journal of Clinical Microbiology.

Much heralded medication for autism is ineffective

A drug thought to work marvels on autistic children has no more effect than a placebo, according to a Yale psychiatrist. In an editorial commenting on a study published Dec. 9 in The New England Journal of Medicine which found secretin no more effective than a placebo, Fred Volkmar, M.D., professor of child psychiatry, noted the considerable interest in the use of secretin, a hormone used to treat gastrointestinal problems, generated by the media. “There is no evidence that it works,” Volkmar said. “There is no reason to think that it would have worked in the first place.” Autism, which affects one child in 2,000, is a brain disorder that results in impaired or delayed social and communication skills. There is no known cure, but early educational and behavioral intervention can significantly facilitate outcome.

A new therapy for prostate cancer

A new radioactive isotope, palladium-103, used for radiation implant therapy for early prostate cancer has proven as effective as an older and more common therapy, but with fewer long-term side effects, a Yale study has found. “The overall cure rates using palladium-103 or iodine-125 appear very similar,” said Richard Peschel, M.D., professor of therapeutic radiology. “However, the newer palladium-103 treatment was better than iodine-125 at preventing both moderate and severe long-term complications.” Peschel tracked 150 patients over seven years for his study, which was published in the Oct. 29 issue of Radiation Oncology Investigations. Peschel attributed the difference in side effects to the higher dose rate for palladium- 103. Palladium doses are given over two months as opposed to six months for iodine.

Also in Rounds:

Malaria makes a comeback  |  Ultrasound an alternative to amnio  |  Is it ever right to practice on the dying?  |  Breast cancer genes  |  Aspirin reduces heart-attack risk  |  Screen for ehrlichiosis  |  Much heralded medication for autism is ineffective  |  A new therapy for prostate cancer          

Chronicle  |  Findings  |  Et cetera

           

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Originally published in Yale Medicine, Spring 2000.
Copyright © 2000 Yale University School of Medicine. All rights reserved.