Sunday, September 21, 2014

D68, Bingo!

Hospitals all around are being inundated with children who come down with a cold or other respiratory virus and wind up with asthma exacerbation. This happens every year to a lot of people. This year it’s happening to a lot more people than in a typical year. We’ve tested a few of those cases, and we’ve determined that Human Enterovirus D68 is responsible for some of those cases.

There are lots of enteroviruses and rhinoviruses. D68 is primarily unusual in that the cold symptoms are quite mild compared to the asthma impact. For people without asthma, D68 seems pretty innocuous. For people with asthma, D68 can land you at the emergency room, admitted to the hospital, or even in intensive care.

I had this exact pattern, with a mild cold that resulted in an urgent care prescription for oral steroids, something I’ve never needed before for my asthma. David just spent three nights hospitalized with the same pattern of a mild cold and serious asthma exacerbation.

A big goal of managing asthma is to prevent hospitalizations, because those are costly and time-consuming and risky. So you make an asthma action plan with the goal of avoiding hospitalizations. If D68 causes a hospitalization, that’s not a failure of the plan. If a non-D68 mild cold causes a hospitalization, that is a failure of the plan. So on a personal level, it would be nice to know if David had D68 or something else.

(Success or failure is a little more complicated than that, of course. The goal of an asthma action plan is to keep the patient as healthy as possible, and to make sure the patient receives the appropriate medical care when needed. Our asthma action plan did not avoid a hospitalization, but it did result in our giving David the appropriate medications at the appropriate times, and getting medical care as soon as it was necessary. In some ways, the plan worked correctly.)

Right now in Massachusetts, D68 can only be tested by sending a sample to the state lab, who then has to send possible positives to the CDC for specific typing. The state lab is only accepting samples from children admitted to an ICU. Nobody else can possibly find out.

Confirmed cases means cases that have been tested positive by the CDC. Suspected cases means cases that fit the pattern, but have not been confirmed. The hospital doesn’t care about the answer for any given patient, because the immediate treatment and precautions during the hospitalization aren’t affected by the answer. The hospitals do care that they are being swamped by cases, and that most of them cannot manage severe cases in-house and have to transfer them to the few and very full hospitals who do have pediatric ICUs. Whether it’s D68 or something else, it’s a resources problem.

But when you read that there are hundreds of suspected cases in Boston, that is the tip of the iceberg. Lots of people are getting D68. Only a subset are children. Only a subset of those children have underlying asthma. Only a subset of those children go to a hospital, and only a subset of those children are admitted, and only a subset of those admitted children land in an ICU, and only that tiny percentage will possibly be tested for D68.

Among the things that health care professionals told me over the past four days in the hospital:

“D68 only infects children.” Children have greater exposures to most viruses because of their large group settings, which is why rhinoviruses and enteroviruses always spread widely when school starts. Children are also less likely to have previously been exposed to any particular virus, and therefore are less likely to have developed an immunity to it. However, we don’t think D68 has spread widely in the past 30 years, and it does appear to be spreading widely right now, so there are plenty of adults right now with exposure and no immunity. And there are plenty of adults with symptoms consistent with D68. We just aren’t testing any adults.

“D68 only infects children with asthma.” This false conclusion is based on children with asthma being the only ones who end up hospitalized from it, and the only ones tested for it.

“D68 in an adult isn’t a problem for that person because we don’t have a shortage of hospital facilities for adults.” Well, speaking for myself, I don’t really like having uncontrolled asthma or the side effects from oral steroids. And if I had to be hospitalized, the fact that I have a greater choice of hospitals doesn’t really make it less of an interruption to my life.

Some things you might like to know: D68 (or any enterovirus) can continue to be shed in stool for weeks, which makes diaper changes an easy route of transmission. Hand sanitizer is ineffective against D68 (or any enterovirus); instead you have to wash your hands with soap and water for at least 20 seconds.

Hospital admissions for kids with a virus causing asthma exacerbation have at least doubled right now because of D68. Other causes haven’t gone away, so any given admission like David’s could easily have been caused by another virus. With shared rooms, shared toys, shared playspaces, a shared kitchen, and naturally imperfect human beings providing health care, putting a dozens kids who each have a 50% chance of having D68 together for a few days is a good way to ensure that they all get D68. But we don’t have oxygen coming out of our wall at home, or continuous O2 sat monitoring at home, or a respiratory therapist coming around every couple of hours at home. So a hospital was the right place for the past several days, even if it gives us an unfortunately higher chance of repeating the experience soon.

Tuesday, September 9, 2014

A tech support note about a TiVo talking to a Mac

Problem: TiVo Premiere (Series 4) stopped seeing the shows that had been uploaded to a local Mac running System 10.5.7. TiVo Transfer on the Mac could still see the TiVo.

Solution: In System Preferences, hold down the Command key while clicking on TiVo Desktop. This will let you see the Videos tab. Check that the Media Access Key is correct, the TiVo Recordings folder location is correct, and that “Publish my videos” is checked. Then press the Stop button, wait a second, and press the Start button. This refreshed the TiVo’s connection to the Mac in a way that rebooting the Mac did not accomplish.

Friday, September 5, 2014