typhoid

2007 -- ALBANY - Gov. Spitzer came full circle in just a week, going from fierce advocate of an unpopular licensing scheme to populist panderer to widespread demands that transit fares stay frozen.

What a difference a disastrous plunge in the public opinion polls can make.

Spitzer, the self-described "f - - -ing steamroller," was more like the tooth fairy yesterday with his sudden pledge to "save the fare" by using nonrecurring "one-shot" revenues to balance the Metropolitan Transportation Authority's precarious budget - at the very time the city is on the brink of a widely expected economic downturn.

The all-but-certain recession - which may be accompanied by a painful burst of the city's real estate bubble - may make the question of substantial fare hikes a matter of when, not if, as fiscal experts predict huge MTA deficits over the next three years.

The situation also means the once-tough-talking Spitzer, now widely considered by his fellow Democrats as "the Typhoid Mary of politics" because of the political damage done to them by his massively unpopular plan to give driver's licenses to illegal aliens, has entered a desperate new phase of his first year in office - one in which he rejects the advice of his own financial professionals in order to curry favor with the voters.

Republican politicians quickly demanded consistency as they called on the governor to freeze the fares on suburban rail lines servicing GOP-oriented riders as well as on the massive state Thruway, where mainly upstate users face massive toll hikes.

Democrats, as well as Republicans, were also wondering what, if anything, the governor would now do in the face of the Port Authority's request for 33 percent fare hikes for bistate travelers.

"Let's put it this way: Taking on the MTA doesn't hurt your poll numbers," observed longtime Democratic consultant - and one-time Spitzer political advisor - Hank Sheinkopf.

Marist College pollster Dr. Lee Miringoff said Spitzer "was going down a road he hasn't been on before - doing a popular thing."

He added, "This won't heal the old wounds but this puts him in the short term presumably on the side the public will be happy with."
South Brother Island, seven acres of dense forest, bittersweet vines, flocks of wild birds and little else, is a speck in the East River — and a glimpse of what the rest of the city might have looked like thousands of years ago.

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Joyce Dopkeen/The New York Times
South Brother Island and its larger sibling, North Brother, lie off Hunts Point. Typhoid Mary was quarantined on North Brother.


The island was sold to a Long Island firm for $10 in 1975.
Historically overlooked and unwanted, it changed hands for $10 in 1975, despite being located in the middle of New York City.

But South Brother, the last East River island of any significant size to remain in private hands, will finally get its due today when it is formally transferred to the city as part of a complex $2 million deal brokered by the Trust for Public Land and financed with federal money secured by United States Representative José E. Serrano.

"The idea of buying an island — I mean, how many people get to buy an island?" said Mr. Serrano, whose district includes South Brother.

South Brother, situated between the Bronx and Queens and within sight of the Rikers Island guard towers, will most likely be left as it is, officials said, preserved as a nature sanctuary and administered by the city's Department of Parks and Recreation.

The island — the smaller sibling of the better known North Brother Island, which is 500 feet to the north and once the quarantine home of Typhoid Mary — suddenly became a desirable property precisely because it had been unwanted for so long.

Neighboring islands, including North Brother, became sites for hospitals that treated infectious diseases like typhus and tuberculosis and for mental hospitals, power plants, jails, homeless shelters and cemeteries for the indigent. But South Brother, neglected by humans, turned into a prime nesting spot for birds and a migration stopping point for such New York City exotica as the great blue heron.

"It is a natural jewel," said Clark Wallace, project manager for the Trust for Public Land, a nonprofit conservation group.

In addition to several types of herons, the island's bird population includes ibises, oyster catchers, cormorants and egrets. In its forest are locust, white mulberry and black cherry trees, covered by thick tangles of oriental bittersweet vines that cover trees and ground alike. Because there are no predators on the island, many birds build their nests on the ground.

K. Jacob Ruppert, whose great-great-uncle Jacob Ruppert Jr. owned the island and was a co-owner of the New York Yankees in the early 1900s, said South Brother was a bird paradise when he paid his only visit in 2004.

"There's no beautiful lagoon," he said. "It's a mound of bird poop. But there are beautiful birds. I never thought I could walk up to a swan on her nest. The ground is nothing but bird droppings and broken egg shells."

But humans, even if few have ever set foot on the island, have had an impact.

During New York City Audubon's annual surveys of the island, volunteers have found dead birds entangled in fishing lines and other debris. Adult birds have been found dead on or near nests that contained unhatched eggs, and Mr. Ruppert said he spotted a television set that had washed ashore.

Maria Torres, president and chief operating officer of the Point, a nonprofit group that is working to revitalize the Hunts Point section of the Bronx, and Mr. Serrano said they had been interested in buying South Brother for the public since 1997. But the owner, Hampton Scows, a Long Island sand and gravel company, had not been interested in selling until recently.

Official with Hampton Scows declined to comment, as did the company's lawyer, Michael McMahon.

But once Hampton Scows signaled its willingness to sell, the Point and the Bronx-based Wildlife Conservation Society, which had received federal money through Mr. Serrano's efforts to buy private land along the Bronx and East Rivers for public use, agreed to pool their money to come up with the $2 million asking price.

Unlike better-known East River islands like Randalls, Roosevelt and Rikers, South Brother's past is murky.

Both North and South Brother Islands were claimed by the Dutch West India Company in 1614, according to "The Other Islands of New York," a book by Sharon Seitz and Stuart Miller, and both were originally named "De Gesellen." (The term was translated as "the companions.")

The islands soon passed into the hands of the English, but remained undeveloped for almost two centuries because of the treacherous currents surrounding them, according to the book.

South Brother may have been a base for Union soldiers during the Civil War, and in about 1894, it was purchased by Jacob Ruppert Jr., a brewing magnate who bought the Yankees with Col. Tillinghast L'Hommedieu Huston in 1915. (Mr. Ruppert's tenure in baseball included the purchase of Babe Ruth from the Boston Red Sox, the opening of Yankee Stadium and eight World Series titles.) Mr. Ruppert built a yacht house on South Brother, and amateur baseball games were held on an adjacent field. Legend has it that Ruth would occasionally show up to practice his swing, swatting balls far into the East River.

After Mr. Ruppert's summer home burned down in 1909, South Brother went through another long fallow period. The island changed hands several more times until 1975, when Hampton Scows bought it for $10.
This week, it's raining fallout, and it feels like a turning point in this series. Two old relationships are reborn and changed; one for the better, one for the worse, and the one sure thing we thought was coming is seemingly nipped in the bud. And Cooper, Cooper, Cooper. Are you really going to make me start liking you?

Like the turkey in about four days, the spoilers are coming.

It's the women vs. the men as all of our doctors recover from their night of stand-ups and hook-ups. But they can't avoid each other. They're all partnered together for "Safe Surrender", a program for mothers who decide to give up their babies. Unfortunately, Addison and Pete are partnered, and babies, the other side of Addison's ever-tossing coin, is the last thing

Addison

needs after an evening of being rejected.

But our girl confronts Pete, and tells him that he's been officially downgraded to acquaintance for his actions.
Addison

then meets one of Violet's patients, Carl (played by Josh Randall, one of my favorites from "Ed"), who calls her for a date. Violet, in her first big realization of client-patient privilege, looks stricken as
Addison

accepts. Carl, in the full disclosure mode, admits that he wants to get married and have kids, and he's also a patient of Violet's.
Addison

comments that she finds that refreshing, and then her phone rings before she can say anything else. It's Pete, with a Safe Surrender call – a little newborn girl has been born to a young woman while her mother slept upstairs.

Once they return to the practice with the baby, Pete tells everyone that Cooper is out on a date, which shakes Violet up, and then
Addison

says her date went well, which also shakes Violet up.
Addison

also tells her Carl admitted to being her patient. But Pete asks Violet what Carl is being seen for, and again, Violet cites her ethics, and tells him to look it up. Hooray for Violet!

Our
Addison

spends the night with someone – the newborn baby. Sensing that they're both alone in the world, she becomes quickly attached to the little girl. But the dreamy baby world of that night is interrupted the next morning, when Carl comes back with flowers for her. A baby and flowers in one day!
Addison

has it all for about 30 seconds, until Pete tells her he doesn't think Carl is "Addison Montgomery Material." She blows him off. However, in the next scene, we find out what Carl's nickname of "trunk" means, and Pete was right. Let's just say that it involves one of
Addison

's shoes in a delicate area. After Carl asks Violet to explain to Addison that he can't see her again, or her shoes, and
Addison

realizes she's going to have to give up the baby, you'd think she'd have enough to deal with, but he and Pete get another Safe Surrender call, only to have that newborn die. Three lost chances. In the end, the baby girl's mother, and grandmother, come back to collect her, making all things right.
Addison

heads home, in tears.

Cooper confronts Violet, who plainly states that she doesn't want to talk, and there's a "world wide web out there" for him. He takes that suggestion eagerly, and jumps back into his comfort zone. But guess who is waiting for him at the other end of the DSL line? Our favorite hospital doctor, Charlotte. She walks out on him, telling him that the moment never happens. Cooper the rejecter becomes the rejected in the same 24 hours. In the end, Violet does talk to Cooper about their failed attempt to be Friends With Benefits, but the uncomfortable issues linger. A great friendship ruined. Cooper then meets up with
Charlotte

, and she retracts the previous rejection. Nudge nudge wink wink.

Sam and Naomi, unlike the other four, keep the news of their rendezvous between themselves. Sam tries to diagnose the evening, asking Naomi what she wants. Naomi reminds him of their previous issues, and tells him she believes it was just a "slip up"… although neither of them seem convinced. After coming to that decision, they make a house call to their priest, who tells them one of their elderly sequestered nuns is sick. Sister Amy (played by Keiko Agena, yet another Gilmore Girls alum! If Lauren Graham is on next week, I'm going to freak out) explains that the nuns do mission trips all over, and since returning from her most recent trip, Sister Helen has been failing. During an examination, Naomi finds small red bumps. As they try and figure out what the rash is, the other nuns start falling ill as well. Sam and Naomi quarantine the convent while they figure out what they're dealing with, which turns out to be typhoid. However, the incubation for typhoid is 2 weeks, and the nuns have been sequestered for more time than that, which means someone is lying about not going out in public. It turns out to be the priest, who has fallen in love with one of the nuns. They've never actually broken any vows, but it's clear to Sam and Naomi that love comes in many forms.

Best Moments:

Addison

's comment that the Safe Surrender baby "should get to feel wanted… for just one night" to Pete was great. It's going to make their eventual hook-up more interesting, once he gets past his grief and she gets past her overwhelming need to be loved.
Jealousy doesn't sit well on Pete. He can't have it both ways – he either has to jump in with both feet or let it go. But, at least he was right about Carl, and he's got way fewer issues.
Sam and Naomi belong together. And Naomi's insistence that God is punishing them by throwing them in the middle of an infectious disease party is really just the opposite. They do belong together. Showing them a couple that can't be for reasons bigger than their own proves that.

Great episode. Addison's emotional frailty is coming to a head, and Pete's inability to connect with anyone romantically is as well. Sam and Naomi make me happy, although they too will wake up to their reality soon enough. And I can't wait to see what happens once Violet realizes who she threw Cooper to.

And just as we're really starting to cook, we're heading into December, and there's no new episode next week. Bummer.



What about you? What character do you think is becoming the most interesting? Do you like the Charlotte/Cooper thing too? What do you think Violet, Sam and Naomi, or Pete and Addison are going to do? Symptoms
Typhoid fever is characterized by a sustained fever as high as 40°C (104°F), profuse sweating, gastroenteritis, and diarrhea. Less commonly a rash of flat, rose-colored spots may appear.[3]

Classically, the course of untreated typhoid fever is divided into four individual stages, each lasting approximately one week. In the first week, there is a slowly rising temperature with relative bradycardia, malaise, headache and cough. Epistaxis is seen in a quarter of cases and abdominal pain is also possible. There is leukopenia with eosinopenia and relative lymphocytosis, a positive diazo reaction and blood cultures are positive for Salmonella typhi or paratyphi. The classic Widal test is negative in the first week.

In the second week of the infection, the patient lies prostrated with high fever in plateau around 40°C and bradycardia (Sphygmo-thermic dissociation), classically with a dicrotic pulse wave. Delirium is frequent, frequently calm, but sometimes agitated. This delirium gives to typhoid the nickname of "nervous fever". Rose spots appear on the lower chest and abdomen in around 1/3 patients. There are rhonchi in lung bases. The abdomen is distended and painful in the right lower quadrant where borborygmi can be heard. Diarrhea can occur in this stage: six to eight stools in a day, green with a characteristic smell, comparable to pea-soup. However, constipation is also frequent. The spleen and liver are enlarged (hepatosplenomegaly) and tender and there is elevation of liver transaminases. The Widal reaction is strongly positive with antiO and antiH antibodies. Blood cultures are sometimes still positive at this stage.

In the third week of typhoid fever a number of complications can occur:

Intestinal hemorrhage due to bleeding in congested Peyer's patches; this can be very serious but is usually non-fatal.
Intestinal perforation in distal ileum: this is a very serious complication and is frequently fatal. It may occur without alarming symptoms until septicaemia or diffuse peritonitis sets in.
Encephalitis
Metastatic abscesses, cholecystitis, endocarditis and osteitis
The fever is still very high and oscillates very little over 24 hours. Dehydration ensues and the patient is delirious (typhoid state). By the end of third week defervescence commences that prolongs itself in the fourth week.


[edit] Diagnosis
Diagnosis is made by blood, bone marrow or stool cultures and with the Widal test (demonstration of salmonella antibodies against antigens O-somatic and H-flagellar). In epidemics and less wealthy countries, after excluding malaria, dysentery or pneumonia, a therapeutic trial time with chloramphenicol is generally undertaken while awaiting the results of Widal test and blood cultures.[4]


[edit] Treatment

Doctor administering a typhoid vaccination at a school in San Augustine County, Texas. Photograph by John Vachon, April 1943.
Typhoid fever in most cases is not fatal. Antibiotics, such as ampicillin, chloramphenicol, trimethoprim-sulfamethoxazole, and ciprofloxacin, have been commonly used to treat typhoid fever in developed countries. Prompt treatment of the disease with antibiotics reduces the case-fatality rate to approximately 1%.

When untreated, typhoid fever persists for three weeks to a month. Death occurs in between 10% and 30% of untreated cases. Vaccines for typhoid fever are available and are advised for persons traveling in regions where the disease is common (especially Asia, Africa and Latin America). Typhim Vi is an intramuscular killed-bacteria vaccination and Vivotif is an oral live bacteria vaccination, both of which protect against typhoid fever. Neither vaccine is 100% effective against typhoid fever and neither protects against unrelated typhus.


[edit] Resistance
Resistance to ampicillin, chloramphenicol, trimethoprim-sulfamethoxazole and streptomycin is now common, and these agents have not been used as first line treatment now for almost 20 years. Typhoid that is resistant to these agents is known as multidrug-resistant typhoid (MDR typhoid).

Ciprofloxacin resistance is an increasing problem, especially in the Indian subcontinent and Southeast Asia. Many centres are therefore moving away from using ciprofloxacin as first line for treating suspected typhoid originating in India, Pakistan, Bangladesh, Thailand or Vietnam. For these patients, the recommended first line treatment is ceftriaxone.

There is a separate problem with laboratory testing for reduced susceptibility to ciprofloxacin: current recommendations are that isolates should be tested simultaneously against ciprofloxacin (CIP) and against nalidixic acid (NAL), and that isolates that are sensitive to both CIP and NAL should be reported as "sensitive to ciprofloxacin", but that isolates testing sensitive to CIP but not to NAL should be reported as "reduced sensitivity to ciprofloxacin". However, an analysis of 271 isolates showed that around 18% of isolates with a reduced susceptibility to ciprofloxacin (MIC 0.125–1.0 mg/l) would not be picked up by this method.[5] It not certain how this problem can be solved, because most laboratories around the world (including the West) are dependent disc testing and cannot test for MICs .


[edit] Transmission

Death rates for Typhoid Fever in the U.S. 1906-1960
Flying insects feeding on feces may occasionally transfer the bacteria through poor hygiene habits and public sanitation conditions. Public education campaigns encouraging people to wash their hands after toileting and before handling food are an important component in controlling spread of the disease. According to statistics from the United States Center for Disease Control, the chlorination of drinking water has led to dramatic decreases in the transmission of typhoid fever in the U.S..

A person may become an asymptomatic carrier of typhoid fever, suffering no symptoms, but capable of infecting others. According to the Centers for Disease Control approximately 5% of people who contract typhoid continue to carry the disease after they recover.


[edit] Epidemiology

Locations of typhoid outbreaks worldwide
With an estimated 16-33 million cases of typhoid annually resulting in 500,000 to 600,000 deaths In endemic areas, the World Health Organisation identifies typhoid as a serious public health problem. Its incidence is highest in children between the ages of 5 and 19 years.[6]


[edit] Heterozygous advantage
It is thought that cystic fibrosis may have risen to its present levels (1 in 1600 in UK) due to the heterozygous advantage that it confers against typhoid fever. The CFTR protein is present in both the lungs and the intestinal epithelium, and the mutant cystic fibrosis form of the CFTR protein prevents entry of the typhoid bacterium into the body through the intestinal epithelium.


[edit] History
Around 430–426 B.C., a devastating plague, which some believe to have been typhoid fever, killed one third of the population of Athens, including their leader Pericles. The balance of power shifted from Athens to Sparta, ending the Golden Age of Pericles that had marked Athenian dominance in the ancient world. Ancient historian Thucydides also contracted the disease, but he survived to write about the plague. His writings are the primary source on this outbreak. The cause of the plague has long been disputed, with modern academics and medical scientists considering epidemic typhus the most likely cause. However, a 2006 study detected DNA sequences similar to those of the bacterium responsible for typhoid fever.[7] Other scientists have disputed the findings, citing serious methodologic flaws in the dental pulp-derived DNA study.[8] The disease is most commonly transmitted through poor hygiene habits and public sanitation conditions; during the period in question, the whole population of Attica was besieged within the Long Walls and lived in tents.

In the late 19th century, typhoid fever mortality rate in Chicago averaged 65 per 100,000 people a year. The worst year was 1891, when the typhoid death rate was 174 per 100,000 persons.[9] The most notorious carrier of typhoid fever—but by no means the most destructive—was Mary Mallon, also known as Typhoid Mary. In 1907, she became the first American carrier to be identified and traced. She was a cook in New York; some believe she was the source of infection for several hundred people. She is closely associated with forty-seven cases and three deaths.[10] Public health authorities told Mary to give up working as a cook or have her gall bladder removed. Mary quit her job but returned later under a false name. She was detained and quarantined after another typhoid outbreak. She died of pneumonia after 26 years in quarantine.

In 1897, Almroth Edward Wright developed an effective vaccine.

Most developed countries saw declining rates of typhoid fever throughout first half of 20th century due to vaccinations and advances in public sanitation and hygiene. Antibiotics were introduced in clinical practice in 1942, greatly reducing mortality. At the present time, incidence of typhoid fever in developed countries is around 5 cases per 1,000,000 people per year.

An outbreak in the Democratic Republic of Congo in 2004-05 recorded more than 42,000 cases and 214 deat