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ANTC68 Final exam notes.docx

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Bianca Dahl

ANTC68 Final exam notes Chronic Diseases- Lecture 12 • Long-term stress activates the hypothalamic-pituitary-adrenal (HPA) axis • There is chronic release of stress hormones (glucocorticoids; cortisol is the most important of these) • Immediate, short-term stress triggers the “fight or flight” response  Blood is diverted to lungs, away from internal organs like stomach and intestines  Heart pumps faster  Dilation of blood vessels  Narrow focus (tunnel vision) • Parasympathetic = part of the nervous system that takes over when you’re calm. • Sympathetic = part of the nervous system that’s activated when you’re stressed. • Long-term stress can be manifested in three ways: 1. “Foot on the gas”: constantly aroused, angry, emotional 2. “Foot on the brake”: withdrawn, depressed, little energy 3. “Foot on both”: freeze under pressure. You appear calm outwardly but inwardly you are anxious, aroused “Our genes load the gun, but the environment pulls the trigger.” • Research in baboons has shown that monkeys at the bottom of the dominance hierarchy show signs of chronic stress. • Stress in childhood leads to: • poor educational attainment • Behavioural problems (hyperactivity, conduct disorders) • Lifetime of emotional problems • Risk of cardiovascular problems in later life • The Whitehall Studies were studies of British Civil Servants • Found: people in the lower pay grade had mortality rates that were 3x higher than those in the highest pay classes • i.e. being at the bottom of the social hierarchy is not good for health • The Black report was done by the UK Department of Health in 1980 • Set out to look at health inequalities • Found that the main explanatory variable for health inequality was economic inequality … despite welfare programs and a national health care plan • Culture includes implicit or explicit guidelines of how to live in society, how we interact with others, and how we see the world • Barriers to healthy eating: high cost of fresh food compared to processed, availability of ethnic foods, availability of foods in inner city, time • Cultural barriers: beliefs in unhealthy ways of cooking (fried foods), ideal body size, medication vs. folk remedies, pride/role of masculinity, value of exercise • Structural barriers: discrimination, transportation, language differences, scheduling As people from countries with low obesity move to the West (ex. USA), they gain weight. It’s not their genes that changed, it’s their environment. • Rates of obesity in the USA are increasing (dramatically) • Women, ethnic minorities most affected • Obesity causes other health problems: sleep apnea, gallbladder disease, arthritis • Why are rates of obesity increasing? • Increased sedentism (staying in one place for a long time without much moving) • “toxic environment” • Heavily processed, high-fat foods low in nutrition • Advertising for above • Example: over the past 30 years, the price of fruit has increased 40%, the price of pop has gone down 33% • Obese people (especially women) complete fewer years of education, are less likely to marry, have lower household income, face discrimination in the job market • Not only does stress increase appetite for high-fat, high-sugar foods, but it decreases our ability to lose weight (physiological response) Samoa Air just announced they will charge passengers by weight • The problem is, large goals are overwhelming, may lead to bingeing behaviour, are less sustainable over the long-term, set up unrealistic expectations • In more severe cases, pharmacological interventions can work • Antidepressants (they have an effect on brain chemistry, can alter hunger while addressing psychological issues) • Gastrointestinal (severe side effects)-> surgeries such as gastric bypass • The industry has made a conscious effort to get people hooked on foods that are convenient and inexpensive • For example: engineers alter levels of individual ingredients and test consumers‟ response • Then they run computer models to find the optimal version, called the “bliss point” Cancer • Includes about 100 related disorders • Occurs when there is a problem with normal cell division resulting in a proliferation of abnormal cells • The word “cancer” comes from the Latin word for crab, perhaps because a tumour with surrounding blood vessels looks like crab legs • Humoural theory explanation: excess of black bile. Melancholic disposition more susceptible. • Hippocrates was the first to differentiate between malignant (bad) and benign (good) tumours • Recommendation was not to perform surgery unless absolutely necessary  Antiseptics weren‟t available until the 1800s: many surgeries resulted in infection  Anesthetics also weren‟t available. Surgery was extremely traumatic  First chemical treatments for cancer started in 1500s  By 1800s, scientists recognized that things that kill cells (chemicals, radiation, X- rays) could be used to reduce tumours  1950: Found heavy smoking increased risk of lung cancer  Mortality from lung cancer declined if individuals stopped smoking  More recently, females are smoking in higher rates than ever despite anti-smoking messages  Current focus on survivorship suggests cancer already cured CVD • 4 main types: cardiovascular disease, cancer, chronic respiratory diseases, diabetes • NCDs account for 63% of global deaths (WHO 2013); 80% occur in low- or middle-income countries Developing countries face a DOUBLE BURDEN of disease where both chronic diseases and acute infectious/malnutrition are a problem. • The Ancient Egyptians (about 3000 years ago) thought the heart was the centre of wisdom, emotion, memory, and personality • CVDs are the #1 cause of mortality worldwide, account for 30% of all deaths • Heart disease likely existed in the past (very old) but it‟s difficult to tell. Usually sudden deaths were explained as a problem with spirits or old age, not the heart • There were taboos on dissecting humans in ancient civilizations, so the role of the heart in pumping blood not recognized • It wasn‟t until 1628 that William Harvey described the heart‟s role in circulation • Experiments with blood transfusions started in the 1660s • Today, the best way to deal with CVD is PREVENTION • chronically stressed populations (low SES) are at greater risk for cardiovascular problems • Barriers to healthy eating: high cost of fresh food compared to processed, availability of ethnic foods, availability of foods in inner city, time “Vanishing caloric density” – if a food melts in your mouth, you assume it has no calories • In the 1950‟s, Doll and Hill wrote to British physicians and asked about their own smoking habits > Mortality from lung cancer declined if individuals stopped smoking • While raising money for cancer research is a good thing, academics/journalists/cancer patients/the public have questioned the overuse of advertising for breast cancer  Changing everything to pink to support breast cancer has been called “pink washing”  Selling everything in the name of „for breast cancer research‟-> to make money • Current focus on survivorship suggests cancer already cured • Emotionally manipulative: campaigns always talk about mothers/sisters having cancer • Breast cancer gets up to 25% of all funding for cancer, more than 2x as much as colon and lung cancers, which are more deadly • Products that support unhealthy lifestyles or are associated with increased risk of breast cancer (through toxins, diet, etc) still go pink EBOLA, SARS, KURU- Lecture 10 • Recall: we thought we had conquered infectious disease after the discovery of effective medications • But since then, there have been dozens of new and “re-emerging” diseases • In 1995 the CDC created the journal “Emerging Infectious Disease” to promote recognition of new diseases and dissemination of information to the scientific community • Notifiable diseases are those that must legally be reported to the government (started with the plague in England) • In Canada, PHAC (Public Health Agency of Canada) maintains a list of over 50 notifiable diseases • The Centre for Disease Control (CDC) in the USA publishes the “Morbidity and Mortality Weekly Report” (MMWR) • First case of Ebola: August 1976: Mabalo Lokela, a schoolteacher, showed up at a mission hospital in Zaire with a fever > They thought he had malaria, gave him chloroquinine • Ebola is a member of the family of filoviruses (looks like spindly filaments) • Filoviruses are very old, although Ebola is quite recent • Four types cause disease in humans: Ebola Zaire, Ebola Sudan, Ebola Bundibugyo, Ebola Ivthy Coast  A 5 type, Ebola Reston, has not been known to cause symptoms in humans • Foege (2000) argues 4 steps are necessary to monitoring diseases, and that it requires USA leadership: • Combine marketplace and disease-control needs (ex: cheaper vaccines/drugs, business compensation) • Thinking about a global plan (human and animal surveillance, rapid diagnostic techniques, modelling) • Global equivalent of EIS • Exert pressure on US political system for leadership in international health • Ebola is a hemorrhagic fever, which means it causes extensive bleeding from orifices • Compared to media portrayals, most bleeding is internal • Case fatality rate of Ebola Zaire = over 90%. Other forms: 50-90% • Spread through personal contact with blood, body fluids, bedding • Treatment: palliative (care for patient but no cure) • The practice of re-using needles contributed to the initial (and subsequent) outbreaks • The mission hospital had 5 needles each day, 500-600 patients • “Barrier nursing” effectively prevents spread: wearing disposable gowns, masks, gloves. Sterilized equipment, removing contaminated bedding. • In 1989, lab monkeys (crab-eating macaque) imported to Reston, Virginia from the Philippines > The monkeys were found to have a filovirus similar to Ebola … turned out to be a new strain, Ebola Reston • Ebola-like diseases captured the public‟s imagination: movies, books • Ebola captured public‟s interest: exotic locales, terrifying symptoms, images of high-tech protective gear (this is why you‟ve heard of it) • Ebola was seen as the most frightening of the “new” viruses (until AIDS) • Ebola can be found in chimpanzees and gorillas; other primates have similar hemorrhagic fevers • Most likely that human epidemics are caused by bushmeat (note: relationship with economics, population increase) • Most likely candidate for natural reservoir: bats SARS, as an influenza-like illness came close to being that big pandemic. • First case: Guangdong province, China. November 16 , 2002 th • human-to-human transmission was limited, but some people were “super- spreaders” able to infect a disproportionately large number of people. • The first super-spreader infected three hospitals and a nephrology professor who then went on to a conference in Hong Kong • Several people at the Hong Kong hotel were infected, and travelled back to Vietnam, Singapore and Toronto • SARS is caused by a coronavirus (SARS-CoV) • Because it was new, no vaccine or effective drug • In Singapore, patients were given home-quarantine orders. Webcams set up to make sure they followed. Severe penalties • Because of its connection with China, Asian residents in Toronto were stigmatized, economic effect on Chinatown • To counteract negative effect on tourism from SARS and the WHO travel advisory, Toronto held “SARStock” an outdoor concert headlined by the Rolling Stones • SARS had never before been recognized in humans  Likely that original source was from animals sold in Chinese markets, such as the palm civet, raccoon dog, ferret badger  Likely wild animal reservoir: bats. Fruit and insect bats spit out food onto forest floor, foraged by other mammals like civets • Sars and Air Travel: Surveillance set up at airports, including heat-sensing technology for detecting fever • SARS officially declared over on July 5, 2003 • CFR = 9.4% highest in elderly (65+) Kuru • In the 1950‟s, researchers discovered a new disease among the Fore people of Papua New Guinea • Those who were afflicted experienced shaking, laughter, uncontrolled motor movements • The name “kuru” comes from the Fore word for „trembling‟ or „fear‟ • When they saw Kuru was fatal, they blamed sorcery • There was a disproportionate mortality among women and children: • 60% of cases were in adult women • Only 2% in adult males  Initial symptoms similar to malaria • Every case is fatal within 12 months Scrapie in Sheep • The neurological symptoms of kuru are similar to a disease seen in sheep (sheep distemper, “scrapie”) • It got its name because affected sheep would scrape against fences, etc. to relieve intense itching (they would scrape off their wool) then die from slow wasting • Within two years, the chimps developed the same neurological symptoms • The virologists had shown that kuru was infectious, not genetic (awarded a Nobel Prize) • It was customary for women and children to prepare bodies for burial and consume parts of the body including the brain • Explained the transmission of kuru, and why it was found mainly in females • Cannibalism was stopped by the Australian government • No new cases of kuru were found in the Fore among anyone born after cannibalism ended • • Kuru is transmitted via endocannibalism (eating dead members of one‟s own tribe) • Believed to be from a single case of a spontaneous genetic mutation that created an abnormal protein in the brain (around 1900) • The incubation period: up to 40 years. • Creutzfeldt-Jakob Disease (CJD): In 1982, it was discovered that it was caused by a new type of infectious agent: a prion (this discovery also got Nobel Prize) • Prion = abnormally folded protein in the brain. Causes proteins around it to denature (unfold). • Creates “holes” in brain, making it look like a sponge • Rare: 1 per million • Symptoms include dementia, memory loss, personality change, motor difficulties, rigid posture, seizures • Different forms of “classic” CJD: • Sporadic: 85% of cases. Spontaneous gene mutation (similar to the one that started kuru) • Familial: 5-15% of cases. Inherited. • Iatrogenic: less than 5% of cases. Spread through contaminated brain products (grafts, electrodes, immunoglobulins, blood transfusions) • Cow 133 turned out to be the first case of BSE, Bovine Spongiform Encephalopathy, aka “Mad Cow Disease” • was a disease in cows that was similar to scrapie in sheep • By 1987, reports started appearing in newspapers about an incurable disease in cows • Public was not informed • Epidemic of BSE linked to farming practice of “rendering” • When cows are killed, they are separated into parts for human consumption and offal (everything else), such as the brain, spinal cord, viscera • The offal is ground up and used to feed new animals • By 1989, British government ordered that brains and spinal cords of cows shouldn‟t enter human food chain • However, there was evidence that the orders weren‟t being carried out properly and offal was ending up in human food • In 1993: first human death from CJD, the human equivalent of BSE • British medical officer still insisted beef was safe • By 1995, four people had died, others were diagnosed • The government eventually issued a warning and advised the destruction of millions of cattle (severe economic losses) • The BSE epidemic spread to other counties in Europe • In France, farmers blamed Britain • It was found that some farmers sold infected meat at the market instead of destroying diseased cattle Tuberculosis- Lecture 9 • Mycobacterium tuberculosis • Recall: Leprosy = Mycobacterium leprae • Slow rate of reproduction • Can survive outside body in dry state for weeks • Thought to have started with agriculture (10,000 years) > Now believed to be much older (35,000 years) • M. bovis *can infect humans via milk, meat Causes non-respiratory forms of TB • M. africanum, M. canetti, M. microti (all rare) • Called “White Death” because of paleness of victims • Tuberculosis bacillus discovered by Robert Koch in 1882, but TB was already declining. WHY? • Improvements in housing, nutrition, hygiene, sanitation, overall standard of living • Public health campaigns to discourage spitting also went a long way toward reducing TB • Bacillus Calmette-Guérin (BCG vaccine), first used 1921 • Prepared from weakened bovine strain • Public slow to accept vaccine, rates increased after WWII • BCG vaccine works well in children to prevent tuberculosis meningitis, but not well in preventing pulmonary TB in adults • Confers protection for 10-15 years • Historically TB was thought to respond to “good air” > Patients would benefit either from cold, mountain air (ex. Swiss Alps) or hot, dry air (ex. Arizona) • Heliotherapy (sun therapy) commonly used for TB patients up until WWII • Sanatoriums would provide palliative care, nutrition, quiet places to rest and convalesce • Over time they became more medicalized, more like hospitals • Treated patients but also infantalized them (treated them like children) • TB sufferers blamed for being morally poor, lacking intelligence, lacking will power. Sanatoria exist to “correct” bad habits. • Streptomycin = first treatment for TB (1944). Injected. Many more followed • Today, we have FIRST LINE drugs (used to treat regular TB). Can use one drug or cocktail of four or five. • MDR-TB = Multi Drug-Resistant Tuberculosis • Resistant to the two most potent first-line drugs (isoniazid and rifampicin) and requires second-line drugs • SECOND LINE drugs (more potent) used sparingly for MDR-TB patients, mismanagement can lead to …. • XDR-TB = Extensively Drug-Resistant Tuberculosis • Resistant to isoniazid, rifampicin, fluoroquinolones (1 -line) AND at least one second-line drug • TDR-TB = Totally drug resistant TB • “hotspots” • China and India have largest number of XDR-TB cases • Regions of the world where MDR and XDR-TB evolving rapidly include Russia (prison population), Estonia, Latvia, Dominican Republic, Argentina • Why can‟t we just treat everyone with as if they had XDR-TB (i.e. give them as many drugs as possible?) • Very expensive (treating regular TB = $50 per patient per year; MDR TB = $5,000-10,000) • 2 line drugs not as effective • Toxic side effects • Risk of resistance • TB diagnosed through observation, X-rays or sputum culture • Distinguishing regular TB from MDR-TB or XDR-TB is much harder > Need to grow sputum sample in culture, may take months to determine resistance status > Meanwhile, patient with XDR-TB may die if left untreated • TB drugs can be potent, have severe effects in body • A barrier to patients completing full course of treatment > Patients may feel that drugs are worse than having TB Directly Observed Therapy Short-Course • A main consequence of inadequate TB treatment is antibiotic resistance • A health care worker administers each dose of drugs • Purpose is to ensure patient takes full regimen instead of stopping halfway through • Treatment of standard TB is 6 months • Treatment of MDR TB is 18-24 months • 13% of TB cases are co-infected with HIV • Potential nosocomial transmission (disease transmission within a medical setting) of TB in HIV clinics • Extra stigma for patients with HIV and TB • Rivalry for resources between HIV and TB programs • WHO recommends all TB patients should be tested for HIV status (currently about 70% worldwide) • WHO also recommends all HIV/TB patients receive antiretroviral therapy (currently about 50% worldwide) • The WHO declared TB to be a “Global Emergency” in 1993 partly as a result of growing poverty and HIV • Paul Farmer (and others) are critical of the term “re-emerging” arguing that TB never went away • In the 1970s and 1980s TB all but disappeared from white people
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