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When An Infected Tooth Becomes Much More

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Earlier this year, a surgical resident was paged to the emergency room to evaluate a man with an angry mass bulging beneath his chin.

Dr. Habib Zalzal half race-walked, half ran to find a panting 40-year-old in obvious distress. In addition to an infection, the man had a choked, high-pitched voice, an elevated tongue, a swollen neck, and a drool. “Please help me,” read the panicked look on his face.

In his patient’s eyes, Dr. Zalzal also saw such hopelessness and fatigue he feared the man might soon stop breathing and die.

Root of the Problem

That’s when the third-year trainee and co-workers went to work—fast. First an anesthesiologist thrust a narrow, curved tube down the man’s windpipe to keep him from strangling; ninety minutes later, he was prepped and draped for an emergency tracheostomy (an artificial opening in the neck) plus multiple incisions to drain stinking, yellow-brown pus.

The ultimate villain? A decayed tooth that had festered for weeks before igniting a wildfire.

Although the name sounds vaguely medieval, in 2018, “Ludwig’s angina” (LA)—the horrific blight just described, in which an infected tooth spreads inflammation throughout the body—remains all-too-familiar in places where poverty and dental neglect overlap.

Zalzal knows this from personal experience. In the two-and-a-half years since leaving Washington D.C. to train as an ear, nose, and throat specialist in Morgantown, West Virginia, the Georgetown medical grad had already seen five or six patients virtually identical to his latest near-death case.

Last year, he also described a technique that can speed LA patients’ recovery. Writing in an international journal of plastic and reconstructive surgery, he and his colleagues touted “negative-pressure wound therapy”—a vacuum-assisted method which boosts blood flow at the same time it sucks bacteria-laced fluid from healing tissues. Nonetheless, even with powerful antibiotics and treatments like this, it can still take weeks for LA sufferers to close their surgical wounds.

Following an initial operation, Zalzal’s most severely-affected patient also needed drainage of his infected mediastinum, the central compartment in the chest housing the heart, esophagus, and great vessels, among other vital structures.

In the pre-antibiotic era, the odds of surviving this would have been nil. How far the world has come since 1836, when the German physician Wilhelm Frederick von Ludwig first reported a curse that felled many people, young and old, over his lifetime.

On the other hand, how far we still have to go.

The Pathway to Peril

Understanding how Ludwig’s angina starts requires a short anatomical primer: The majority of LA cases result from infected second and third molars whose roots penetrate the upper and lower jawbone. Infection of these bones can subsequently spread to internal spaces (specifically, the “submaxillary” and “sublingual” space) and spread beneath the tongue. In the worst-case scenario, a noose of inflammation encircles the entire windpipe, threatening to completely obstruct the passage of air. An inability to swallow their own secretions furthers the risk that patients will asphyxiate. Then there are the bacteria that trigger the process in the first place. Without belaboring their long, arcane names, in the nooks and crannies of rotting teeth live some pretty rotten microbes.

“The pain alone should alert the patient to seek care [for Ludwig’s angina], but life-threatening swelling can develop very quickly,” Zalzal says. The condition may sound like it belongs in another era, but there a number of factors contributing to West Virginia’s high number of cases. “First of all, in this state, Medicaid doesn’t cover routine dental check-ups and maintenance,” he says, “which is one reason why missing teeth are so common.” Shockingly, roughly one in four working class adults in West Virginia has already lost six or more teeth, while 38 percent of seniors have no teeth at all.

Zalzal also cited the state’s poverty, its low uptake of fluoridation, and a general shortage of dentists, especially in rural and mountainous areas, as additional components of the area’s high prevalence of dental problems.

Ironically, most medical articles about Ludwig’s angina are now authored in low-income countries as opposed to rich ones like ours. On the other hand, the common denominator between West Virginia and, say, rural India is a comparable dearth of dentists and preventative oral health measures.

Global Tooth Decay

In 2015, the Global Burden of Disease study found that oral health remains an ongoing, worldwide challenge. Between 1990 to 2015, the estimated number of people with untreated disorders rose 40 percent and included 2.5 billion with carious permanent teeth.

The hidden cost of this burden is huge.

Consider these facts. In addition to causing pain, dental cavities, gingivitis, and gum infections also contribute to an increased risk of cancer and cardiovascular disease. They hinder healthful eating. And, last but not least, they stigmatize. As public health professor Austin Frakt wrote in the The New York Times in February 2018, “…we make judgments about one another—including about intelligence—according to the aesthetics of teeth and mouth.”

A pointed take-home in Frakt’s article was Medicaid’s patchy and inadequate state-by-state coverage of various dental services. Nor does Medicare cover routine dental checkups, fillings, or extractions, he added in a follow-up article published a few weeks later.

Which brings us back to one doctor’s first-hand experience in a famously rugged Appalachian state. Although much has been written in recent years about better oral health for all, West Virginia’s revolving door of Ludwig’s angina patients tells a different story. To Zalzal, it’s just the tip of a giant iceberg—or perhaps of a jagged, broken tooth.

It’s also a guaranteed adrenaline rush. “Does your pulse pick up when you get called to see a case?” I asked as our conversation drew to a close. “Oh yeah,” he replied. “I’m thinking: Oh no, I have to drop everything and go to the ED [Emergency Department] NOW, I’ve gotta make quick decisions. Ludwig’s angina causes airway obstruction, which is one of our leading, life-threatening emergencies.”

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The Aftermath of Michael Jackson’s Antigravity Lean

The infamous lean.

In Michael Jackson’s 1987 music video “Smooth Criminal,” the legendary performer leans forward 45 degrees from a straight-up position — and comes back. It’s a feat that seemingly defies both physics and physiology, and the move has become another element of MJ’s aura of mystery.

Some type of cinematic or mechanical trick must be responsible, since most people can manage only a 20-degree forward tilt before toppling headlong. Yet Jackson performed the move live on tours around the world for years.

Lean In

In a study published this week in the Journal of Neurosurgery, three scientists examine the so-called Antigravity Lean, not from a physics but from a physiological perspective. The three neurosurgeons, all at the Postgraduate Institute of Medical Education and Research in Chandigarh, India, combine in the article their knowledge of Jackson with data on spine biomechanics.

It’s been known for years how Jackson defied gravity. His shoes had a slot that slid onto a bolt in the floor, allowing him to perform the dramatic lean.

Bending forward is limited by the erector spinae muscles, which act like cables to support forward bends up to 20 degrees, though some dancers can achieve 30 degrees, the paper says. When near the max of a bend, you can feel the strain on the Achilles’ heel as the ankles become the fulcrum for balance. People soon return to vertical or catch themselves from falling headlong.

Though Jackson’s 45-degree bend is not physically possible without trickery, the King of Pop still needed incredible core strength and leg muscles to pull it off, the authors write. Not just anyone can lock their shoes into the floor and become Michael Jackson, it seems.

“Several MJ fans, including the authors, have tried to copy this move and failed, often injuring themselves in their endeavors,” the researchers write.

Figure A shows the Antigravity Tilt (a 45-degree forward bend) and the normal limit that most people can bend forward. Jackson used shoes with a slot that slid onto a bolt in the floor. Figure B shows the shift when the body’s fulcrum is the hip and when it’s the Achilles’ tendon. (Illustration courtesy of Manjul Tripathi)

Figure A shows the Antigravity Tilt (a 45-degree forward bend) and the normal limit that most people can bend forward. Jackson used shoes with a slot that slid onto a bolt in the floor. Figure B shows the shift when the body’s fulcrum is the hip and when it’s the Achilles’ tendon. (Illustration courtesy of Manjul Tripathi)

Tough Act to Follow

Jackson’s sleight of foot inspired generations of dancers who push the limits physically. This has resulted in spinal stresses not previously seen by neurosurgeons.

This is not to point the finger at Jackson. But it does suggest the reality that injuries can occur that might require implant spinal surgery, the article says, something potentially devastating to a dancer.

But it’s not all bad news — neurosurgeons have gained a lot of new information on how to treat spinal cord injuries in recent years, something that could be in part thanks to MJ’s envelope-pushing dance moves.

“The King of Pop has not only been an inspiration but a challenge to the medical fraternity,” Tripathi says.

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Your Emergency Contact Does More Than You Think

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You know when you’re filling out your medical paperwork and it asks for your emergency contact? Sure, the process might be annoying, but that emergency contact could actually be put to good use by researchers.

Since many of us use a family member, those contacts can help scientists create family trees. And they can also be used for genetics and disease research, according to a study released Thursday in Cell. Discovering what diseases are inheritable can be a laborious and expensive process — patients must be recruited and researchers must clearly determine patients’ phenotypes (physical traits that include eye color, height, and overall health and are often influenced by your genes).

To make that process easier researchers from three major New York medical centers generated family trees from millions of electronic medical records to create a database.This is the first time electronic health records have been used to trace ancestry and it’s the largest study of heritability using such records.

The More You Know

The researchers identified 7.4 million relatives with an algorithm that matched names, addresses and phone numbers from three medical centers. They found 500 inheritable phenotypes in the data just by looking at test results and observations in health records. The traits included diseases affecting skin, blood and mental health.

The data can help determine the heritability level of many common diseases. For example, researchers found that having an increase of HDL (good) cholesterol is 50 percent heritable, while LDL (bad) cholesterol is only 25 percent heritable. The study’s findings were consistent across the participating medical centers and published studies.

Previous heritability research primarily documented Caucasians of northern European descent, according to the study’s first author Fernanda Polubriaginof, but this research is much broader.

“This dataset will allow us for the first time to compute whether there are differences in other races and ethnicities,” said Polubriaginof in a news release.

Future studies could look at medical records for the hereditary contribution of any trait. Due to privacy issues, patient identifiers were removed for the data, which can only be used for research at the moment. Though, with patient consent, emergency contacts could be put to important use in the future.

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Mosquito Bites Leave A Lasting Impression On Our Immune System

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Mosquito bites are like a gross form of French kissing — the insects swap your blood with their saliva, and leave a trail of salivary secretions behind like mosquito cooties. Some of those compounds prevent clotting as the insects slurp up your blood. Now researchers find mosquito spit aggravates your immune system for days afterward. The findings could help scientists develop vaccines for mosquito-born diseases like Zika.

Rebecca Rico-Hesse, a virologist at Baylor College of Medicine in Houston, Texas, wanted to know how mosquitoes exploit our immune systems with their drool. So, she and her team exposed mice with human-like immune systems to live mosquitoes. Then, they sized up the mice’s immune response as it reacted to the mosquito spittle.

The bug’s saliva toyed with their immune systems in both bone marrow and skin cells with effects that lasted up to seven days after biting, the team reports today in PLoS: Neglected Tropical Diseases. The researchers say their discovery could explain how these tissues might act as virus incubators and help spread disease.

Master Manipulators

In 2012, Rico-Hesse was looking to untangle how Dengue virus causes Dengue hemorrhagic fever — an illness that affects 400 million people each year and can lead to death — when she came across a strange occurrence. Mice infected with the virus from mosquito bites fared far worse than mice that had received an injection of the virus but hadn’t been served as a mosquito meal. The result made Rico-Hesse take a step back.

It seems that mosquito bites caused the immune system to behave differently, and in ways that could potentially give infectious diseases a leg up.

To find out, Rico-Hesse and her team set starving Aedes aegypti mosquitoes on mice that had received a dose of human stem cells to make their immune systems look more like a human’s. Each mouse endured eight mosquito bites total. Then the team checked out different parts of the immune system — blood, bone marrow, spleen, and skin cells — six and 24 hours after biting, as well as seven days later. By then, the immune system should have returned to normal.

Sneaky Viruses

Instead, the team discovered immune cells that had disappeared from the skin at least six hours post-bite came back seven days later after maturing in bone marrow, something that shouldn’t have happened. If those cells harbored a virus, they could then pass it on to new mosquitoes, who could infect others.

The research is pointing out new ways in which mosquito bites affect our immune systems, and it goes beyond simple itching and scratching.

“Mosquito saliva has evolved to modify our immune system,” Rico-Hesse said. And as their new research shows, viruses and parasites could be hijacking that activity to get to the cells they reproduce in, like bone marrow cells, faster, according to her.

Essentially, viruses might be taking advantage of the immune system’s response to travel from their point of entry — the skin — to a place they can multiply in that’s away from attacks by the immune system.

“It’s mind-blowing,” Rico-Hesse said. “No one has ever seen this before.”

Ultimately, the work could lead to infection-blocking vaccines, said Duane Gubler, an international health expert who was not involved in the research.

That’s what Rico-Hesse hopes, too. “If we can make a vaccine that would protect us against the effects of the [mosquito] saliva, or blocking our immune reaction … then we could stop global vector-born diseases,” she said.

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