New England Journal of Medicine

wealthy-americans-have-death-rates-on-par-with-poor-europeans

Wealthy Americans have death rates on par with poor Europeans

America, Europe, health, health disparity, life expectancy, lifespan, New England Journal of Medicine, wealth, wealth inequality / /

“The findings are a stark reminder that even the wealthiest Americans are not shielded from the systemic issues in the US contributing to lower life expectancy, such as economic inequality or risk factors like stress, diet or environmental hazards,” lead study author Irene Papanicolas, a professor of health services, policy and practice at Brown, said in a news release.

The study looked at health and wealth data of more than 73,000 adults across the US and Europe who were 50 to 85 years old in 2010. There were more than 19,000 from the US, nearly 27,000 from Northern and Western Europe, nearly 19,000 from Eastern Europe, and nearly 9,000 from Southern Europe. For each region, participants were divided into wealth quartiles, with the first being the poorest and the fourth being the richest. The researchers then followed participants until 2022, tracking deaths.

The US had the largest gap in survival between the poorest and wealthiest quartiles compared to European countries. America’s poorest quartile also had the lowest survival rate of all groups, including the poorest quartiles in all three European regions.

While less access to health care and weaker social structures can explain the gap between the wealthy and poor in the US, it doesn’t explain the differences between the wealthy in the US and the wealthy in Europe, the researchers note. There may be other systemic factors at play that make Americans uniquely short-lived, such as diet, environment, behaviors, and cultural and social differences.

“If we want to improve health in the US, we need to better understand the underlying factors that contribute to these differences—particularly amongst similar socioeconomic groups—and why they translate to different health outcomes across nations,” Papanicolas said.

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Burning in woman’s legs turned out to be slug parasites migrating to her brain

Angiostrongylus cantonensis, case study, health, Infectious disease, Massachusetts General Hospital, New England Journal of Medicine, parasites, rat lungworm / /

It started with a bizarre burning sensation in her feet. Over the next two days, the searing pain crept up her legs. Any light touch made it worse, and over-the-counter pain medicine offered no relief.

On the third day, the 30-year-old, otherwise healthy woman from New England went to an emergency department. Her exam was normal. Her blood tests and kidney function were normal. The only thing that stood out was a high number of eosinophils—white blood cells that become active with certain allergic diseases, parasitic infections, or other medical conditions, such as cancer. The woman was discharged and advised to follow up with her primary care doctor.

Over the next few days, the scorching sensation kept advancing, invading her trunk and arms. She developed a headache that was also unfazed by over-the-counter pain medicine. Seven days into the illness, she went to a second emergency department. There, the findings were much the same: Normal exam, normal blood tests, normal kidney function, and high eosinophil count—this time higher. The reference range for this count was 0 to 400; her count was 1,050. She was given intravenous medicine to treat her severe headache, then once again discharged with a plan to see her primary care provider.

At home again, with little relief, a family member gave her a prescription sleep aid to help her get some rest. The next day, she awoke confused, saying she needed to pack for a vacation and couldn’t be reasoned with to return to bed. After hours in this fog, her partner brought her to an emergency department for a third time, this time the one at Massachusetts General Hospital.

Getting warmer

In a case report published in the New England Journal of Medicine, doctors explain how they figured out the source of her fiery symptoms—worms burrowing into her brain. By this point, she was alert but disoriented and restless. She couldn’t answer questions consistently or follow commands.

The doctors at Mass General, including a neurologist specializing in infectious diseases, quickly focused their attention on the fact that the woman had recently traveled. Just four days before her feet began burning, she had returned from a three-week trip that included stops in Bangkok, Thailand; Tokyo, Japan; and Hawaii. They asked what she ate. In Thailand, she ate street foods but nothing raw. In Japan, she ate sushi several times and spent most of her time in a hotel. In Hawaii, she again ate sushi as well as salads.

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Parenting nightmare: Kiss on the cheek causes child’s incurable infection

cold sore, cold sores, health, herpes, herpes simplex virus type 1, HSV-1, infectious diseases, New England Journal of Medicine, Science / /

Stress of parenting —

Puzzle of child’s misdiagnosed cheek lesion solved with one look at dad

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Herpes simplex virus, (HSV). Image taken with transmission electron microscopy.

Enlarge / Herpes simplex virus, (HSV). Image taken with transmission electron microscopy.

As the US Surgeon General recently highlighted, parenting is stressful. From navigating social media to facing a youth mental health crisis, challenges abound. But, for one father in Spain, even the simple, loving, everyday act of giving your child a peck on the cheek has turned to nightmare fuel.

According to a case report in the New England Journal of Medicine, the man’s 9-year-old daughter developed a fever along with a crusty, blistering lesion on her left cheek. Doctors initially diagnosed the blotch as impetigo, a bacterial infection on the skin’s surface layers that is fairly common in children. It’s often caused by Staphylococcus aureus or Streptococcus bacteria and is generally easily treated with antibiotics.

The lesion on the girl's cheek with satellite blisters noted by arrows.

Enlarge / The lesion on the girl’s cheek with satellite blisters noted by arrows.

But, after several days of treatment for impetigo, the child’s symptoms weren’t getting better. At that point, it had been seven days since the lesion erupted, and it was 3 centimeters in diameter on the side of her face. So, he took her to a dermatology clinic. There, specialists closely examined the lesion, noting the red, raised area with blisters and a “honey-crusted appearance,” which is a classic sign of impetigo. They also noted smaller “satellite” blisters around the cheek, as well as swollen lymph nodes on the left side of her neck, the same side as the lesion. All of the symptoms still lined up with impetigo. But then the specialists looked over at her dad.

The doctors took note of a crusting on her father’s lower lip, which he said had started 10 days earlier. It looked like a classic case of common cold sores, aka oral herpes. And the doctors made a connection.

Stress begets stress

Cold sores are caused by herpes simplex virus type 1 (HSV-1), a highly contagious virus that is estimated to infect 3.7 billion people under the age of 50 globally. (There’s also HSV-2, which causes genital herpes). In an initial infection, herpes viruses invade cells on the body’s surfaces, but then go into hiding in nerve cells. From there, they can occasionally reactivate and produce new lesions and infections. For HSV-1, that usually means cold sores around the mouth.

There is no cure for herpes infections; the virus will lurk in a person’s nerve cells for the rest of their lives, with the potential to spur recurring outbreaks. However, there are antiviral treatments that can ease the symptoms of outbreaks and help them clear up a little faster.

When a cold sore develops, the lesions are highly infectious. It’s often transmitted through oral-oral contact, but any direct contact or contact with contaminated saliva can spread the virus. (HSV-2 primarily spreads through sexual contact.) And, while HSV-1 lesions typically erupt around the mouth and on mucosal surfaces, they can sometimes also flare elsewhere on the skin.

The dermatologists treating the 9-year-old ran a test for HSV-1, confirming the genetic traces of the virus were present. They started the girl on an oral antiviral drug. They also noted that there was no concern for sexual abuse. The lesion cleared without scarring.

In their report on the case, they end with a note of caution for other doctors: “When HSV-1 infection manifests in children as cutaneous lesions without mucosal involvement, it may be confused with the honey-crusted appearance of impetigo.”

For parents, the lesson is to be careful not to kiss your child (or anyone else) when you have a cold sore flare up. While those viral reactivations can be sparked by many things, one notable factor will likely strike home for parents: stress.

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The puzzling case of a baby who wouldn’t stop crying—then began to slip away

babybig, botulism, health, infant botulism, medical case, NEJM, New England Journal of Medicine, Science, toxins / /
A studio portrait of a crying baby.

Enlarge / A studio portrait of a crying baby.

It’s hard to imagine a more common stressor for new parents than the recurring riddle: Why is the baby crying? Did she just rub her eyes—tired? Is he licking his lips—hungry? The list of possible culprits and vague signs, made hazier by brutal sleep deprivation, can sometimes feel endless. But for one family in New England, the list seemed to be swiftly coming to an end as their baby continued to slip away from them.

According to a detailed case report published today in the New England Journal of Medicine, it all started when the parents of an otherwise healthy 8-week-old boy noticed that he started crying more and was more irritable. This was about a week before he would end up in the pediatric intensive care unit (PICU) of the Massachusetts General Hospital.

His grandmother, who primarily cared for him, noticed that he seemed to cry more vigorously when the right side of his abdomen was touched. The family took him to his pediatrician, who could find nothing wrong upon examination. Perhaps it was just gas, the pediatrician concluded—a common conclusion.

Rapid decline

But when the baby got home from the doctor’s office, he had another crying session that lasted hours, which only stopped when he fell asleep. When he woke, he cried for eight hours straight. He became weaker; he had trouble nursing. That night, he was inconsolable. He had frantic arm and leg movements and could not sleep. He could no longer nurse, and his mother expressed milk directly into his mouth. They called the pediatrician back, who directed them to take him to the emergency room

There, he continued to cry, weakly and inconsolably. Doctors ordered a series of tests—and most were normal. His blood tests looked good. He tested negative for common respiratory infections. His urinalysis looked fine, and he passed his kidney function test. X-rays of his chest and abdomen looked normal, ultrasound of his abdomen also found nothing. Doctors noted he had high blood pressure, a fast heart rate, and that he hadn’t pooped in two days. Throughout all of the testing, he didn’t “attain a calm awake state,” the doctors noted. They admitted him to the hospital.

Four hours after he first arrived at the emergency department, he began to show signs of lethargy. Meanwhile, magnetic resonance imaging of his head found nothing. A lumbar puncture showed possible signs of meningitis—high red-cell count and protein levels—and doctors began courses of antibiotics in case that was the cause.

Six hours after his arrival, he began losing the ability to breathe. His oxygen saturation had fallen from an initial 97 percent to an alarming 85 percent. He was put on oxygen and transferred to the PICU. There, doctors noted he was difficult to arise, his head bobbed, his eyelids drooped, and he struggled to take in air. His cry was weak, and he made gurgling and grunting noises. He barely moved his limbs and couldn’t lift them against gravity. His muscles went floppy. Doctors decided to intubate him and start mechanical ventilation.

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